Inspection on 17/04/08 for Rosemary Retirement Home

This inspection was carried out on 17th April 2008.

CSCI found this care home to be providing an Adequate service.

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

Rosemary Retirement Home 18/04/07

Rosemary Retirement Home 06/03/06

Rosemary Retirement Home 21/03/05

Rosemary Retirement Home 07/12/04

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 Retirement Home 65 Vicarage Road Wollaston Stourbridge West Midlands DY8 4NP Lead Inspector Mrs Jean Edwards Key Unannounced Inspection 16th April 2008 07:25 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 Rosemary Retirement Home DS0000024975.V362302.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 Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemary Retirement Home Address 65 Vicarage Road Wollaston Stourbridge West Midlands DY8 4NP 01384 397298 01384 393506 rosemary@yescomputers.co.uk 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) Rosemary Limited Mrs Kathleen Oakley Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability over 65 years of age (8) of places Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th April 2007 Brief Description of the Service: Rosemary Retirement Home is registered to provide residential care for up to 23 people over the age of 65, including 8 with a physical disability. The property is a large detached house located in Wollaston within a residential area close to shops and easily accessible by local public transport. Parking is provided at the front of the property with landscaped gardens at the rear. Ramps enable easy access for wheelchair users. Accommodation is provided over 3 levels. Access at the front is to the ground floor where there is a conservatory, dinning room, main lounge area, kitchen, laundry room, single toilet, and bathroom with single toilet, office, staff toilet and bedrooms. The lower ground floor is accessed via stair or open lift and forms part of the new extension. This comprises a small open lounge, shower room and toilet, and six bedrooms with en-suit facilities. The remaining bedrooms, bathroom with toilet and walk in bath and toilet are on the 1st floor accessed by stairs or vertical lift. Information relating to the up to date level of fees, including a range of individual third party top up fees, can be obtained directly from the home. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, the Commission for Social Care Inspection (CSCI), undertook an unannounced key inspection visit. This means the home has not been given prior notice of the inspection visit. A CSCI inspector spent one weekday at the home from 07:35 to 20:40 hours, accompanied for part of the inspection by the CSCI pharmacy inspector. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements includes: discussions with the registered proprietor, registered manager and staff on duty during the visit, discussions with residents, observations of residents without verbal communications and examination of a number of records. We also spoke to relatives, district nurses and other professionals who visited the home. Other information has been gathered before this inspection visit including the home’s Annual Quality Assurance Assessment (AQAA), notification of incidents, accidents and events submitted to the CSCI. An anonymous complaint containing allegations sent to the CSCI has also been looked into as part of this key inspection. We took resident surveys, relatives surveys, health care professional and staff surveys to the home to be distributed and requested they be returned to the CSCI office in Birmingham to be collated and included as part of this report. There were 23 residents living at Rosemary Retirement Home. Formal interviews with residents were not always appropriate therefore other methods such as observations of body language, eye contact, gestures, interactions between staff and residents have been used. There was a tour of the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission, where possible. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. What the service does well: The Residents, relatives, district nurse and other visitors continue to express high levels of satisfaction with the care, food, environment and staff. The home has easy to read information available about the service, which helps people to make decisions about where to live. A relative commented, very happy with care, there is a nice atmosphere, staff are brilliant, there is good interaction, Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 6 they provide activities and keep people busy, the standard of care given is very good Residents were very complimentary about the care and support from the proprietor, manager and staff. The majority of people feel they always receive prompt attention at the time they need it. One person we had not formally interviewed made a special effort to speak to us to tell us, “staff here are wonderful and we are well cared for”. We noted that visitors were warmly welcomed to the home and offered refreshments, support and appropriate information, for example a person looking for a care home for a relative came to the home to look around, and even though there were no vacancies requested that they be put on a waiting list. The home provided wholesome, nutritious meals and residents were very complimentary, they told us that they really enjoyed the meals, especially the home made, afternoon snacks. Hot and cold drinks are available throughout the day and staff encouraged people to have plentiful drinks. We observed that staff were sensitive in their approach when helping people needing assistance with feeding, allowing them to eat at their own pace. The environment was well maintained, homely and comfortable. It was well lit, warm and clean. Residents were encouraged to personalise their own rooms and the registered manager asks families to bring personal possessions to make the bedrooms more familiar, which helps new residents to settle in. This inspection was conducted with full co-operation of the Registered Proprietors, Registered Manager, Administrator, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspectors would like to thank the proprietors, manager, staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? There were some more small improvements to the way the home plans each persons care. There was also improved usage of health screening so that residents needs could be identified at an early stage. The records to show that residents have access to dental care, opticians, chiropodists and other services have improved. There were records to show that residents dietary needs and their weights were monitored, with advice requested from GPs and dieticians as needed. Improvements had been made to the environment; the drive had been tarmaced making walking easier for residents and others with mobility Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 7 problems. There was a new roof on the conservatory, with added ventilation and a number of residents’ bedrooms had been redecorated. The improvements to individual staff training had continued showing that they have received training to improve their skills and knowledge, which benefits people living at the home. The home had increased the ratio of care staff with an NVQ 2 award to 75 . The home had strived to increase activities on offer for residents, mainly provided in the home. We observed the movement to music session on the morning of this inspection visit, which the majority of residents enjoyed participating or watching. There were also examples around the home of handicrafts made during craft sessions. The registered manager had made some improvements to the recruitment processes and staff personnel records, making sure no staff are employed at the home until essential clearances from the Protection of Vulnerable Adults (POVA) Register and Criminal Records Bureau (CRB) were obtained. There were some areas of record keeping and compliance with health and safety, which had improved, particularly accident analysis. What they could do better: The care plans need further development to record fuller details of care needs and guidance for staff to make sure that all resident’s needs are properly met. The homes system for the management and administration of residents medication must be improved in a number of areas so that it is a safe as possible. Examples were that staff must receive more comprehensive training from an accredited trainer, that medication storage and records must be improved in accordance with advice from the CSCI Pharmacy Inspector. As highlighted at previous inspections the improvements to provide more activities and outings must be built on. The home must offer more individual activities for people with dementia or sensory loss with each persons participation or refusal accurately noted. Surveys contained comments such as provide more activities and outings for residents. The registered manager must submit staffing proposals, to the CSCI for consideration, taking account of residents’ dependency levels and using a staffing tool such as the Residential Forum Staffing Tool provided as part of the Department of Health guidance, We have noted that care staff still do some cooking and laundry, especially on late shifts, which detracts from time to directly attend to residents care needs. The registered persons must also seriously consider the staffing structure and ensure that there is a suitably qualified, experienced and competent person designated to be responsible for the home on every shift, throughout the 24 hours, documented on the staff rota. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 8 As required at previous inspections there were areas of staff recruitment, which still needed further improvement, such as fuller employment histories on application forms to make sure there are no unaccounted for gaps in employment. The home should also expand the health declaration as part of the recruitment process to make sure that staff are fit to undertake the duties expected to care and support residents. The registered persons must complete the processes to put in place a robust quality assurance system to measure and monitor the homes performance, using questionnaires and other means to seek the views of residents, relatives and other professionals in the wider community. There are a number of records and areas of health and safety, which must be improved to safeguard the residents. For example the registered manager should expand the accidents analysis to identify any trends or unforeseen risks and to put additional controls in place to minimise risks where possible. 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 Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 9 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 Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 10 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, 5, Quality in this outcome area is good. The home has an easy to read statement of purpose and service user guide and residents have a contract / terms and conditions of occupancy, which provides residents and their advocates with information about how care will be provided, their rights and entitlements, and any agreed restrictions. The home uses comprehensive assessment tools, which means that residents’ needs are assessed to ensure that their care needs will be met. The home actively encourages introductory visits and there is evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. Standard 6 is not applicable This judgement has been made using available evidence including a visit to this service. EVIDENCE: During this inspection visit we looked at a sample of four residents’ case files, we have spoken to the residents, three relatives, an activities provider, district Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 11 nurse and the staff on duty. We noted that the home had an updated statement of purpose, service user guide and complaints procedure located in the reception area. The statement of purpose and service user guide provided good, clear, easy to read, information about the home and the complaints procedure has been provided in formats suited to the residents’ capabilities. Examination of residents case files and discussions with residents and relatives confirmed that they had been given copies of the homes statement of purpose, service user guide and complaints procedure. There was evidence from the CSCI service user and relatives surveys and from a sample of case files that each resident was provided with a contract / statement of terms and conditions, including their individual fees. There were 23 residents accommodated. Discussions with registered manager and deputy manager and assessment of the AQQA information supplied by the home, indicated an awareness that if and when residents deteriorate and they may need care, which the home is not able and not registered to provide, they would be supported to access a more appropriate placement. We looked at the care records of two of the residents most recently admitted to the home. The files contained information showing that families visited the home prior to agreeing the admission, the registered manager’s pre-admission assessment, together with the letters from registered manager confirming the home could meet the prospective residents’ needs in compliance with Regulation 14(1)(d). There were also copies of assessment information from the referral agencies, for example Dudley Social Services SAP10 form. The home’s assessments included information relating to preferences and activities. The assessment information could be linked in more fully to detailed needs, goals and guidance in the care plans. The staff spoken to demonstrated that they were aware of residents’ needs, and there were generally good records of each residents preferences such as rising, retiring, likes and dislikes, which reduced risks posed by reliance on verbal communication between staff. However some people’s preferred times of rising had changed to an earlier time and the changes had not been updated. A relative of a resident, who was looking for a care home came to look around and even though there were no vacancies, the manager and staff were welcoming and informative. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is adequate. The care planning and risk assessments provide staff with the information they need to adequately meet residents needs. There is good multi disciplinary working taking place on a regular basis, which results in the health needs of residents being met. The arrangements for administration of medication do not protect residents from potential risks to their health and well being. Residents are treated with sensitivity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home’s AQAA submitted on 26 March 2008 stated, What we do well: “produce care plans, assessments for mobility, nutrition, tissue viability. Staff training in all areas of care i.e. NVQ, staff encourage residents to be independent where possible, the staff assessed in all areas of personal hygiene. Complying with drugs policy. Consult with health professionals. Staff respect privacy/dignity/double room screen. All residents receive mail unopened. Staff ensure residents wear own clothes. Residents are addressed in their chosen manner. All residents use a GP of their choice/families/”. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 13 We examined a sample of three resident’s case files in detail and looked at three others in less depth. All residents’ files examined showed that residents have a plan for their care needs, with evidence of the involvement of the person and / or their family where appropriate, in the development and review of the plan, which demonstrated good practice. We also used a short observational framework inspection method (SOFI), where we sat in the communal lounge and dining room for an hour and fifty minutes. We used this time to observe and record information about 3 residents who were not able to express themselves verbally, including any interactions with staff, other residents or their surroundings. One person, whose care we have looked at had complex needs, such as previous strokes, angina, confusion and was mainly cared for in bed or in a chair in the bedroom. This person also had a pressure ulcer. The care plan and health screening assessments contained basic information but lacked the detail and guidance needed to make sure all staff were fully informed. However at a practical level the residents’ needs were generally being met. A pressure relieving mattress and cushion were in place. Food was being liquidised and there was evidence that this person has a good appetite and takes food well. The district nurse and GP have indicated that they were satisfied with the care provided and have commented that it was positive that the person is maintaining weight. In addition the pressure ulcer has improved from grade 4 to grade 3, with continued support from the district nurses. There was evidence that the manager had implemented short term care plans, provided documented information to demonstrate changing actions to show how short term care needs were met. An example was when a resident had a urinary tract infection and needed more care, with a course of antibiotics and extra fluids. Though this demonstrated a positive approach to give staff additional guidance, it only stated, “push fluids – not to have cups of tea - next few days juice or water.” This gave no indication as to discussion, preferences or agreement with the resident or relatives. There was a range of risk assessments in place, though one of the tissue viability assessments had not been reviewed following a deterioration of the resident’s condition. There were moving and handling risk assessments in place, though these needed to identify more clearly the level of assistance required for each transfer and must be updated accurately as needs changed. There were also nutritional scores and falls risk assessments, though the staff guidance and interventions needed were not detailed. For example one persons risk assessment indicated verbal and physical aggression but stated, “only happens if woken up.” The home did not have forms to monitor and evaluate. We have recommended that the manager consider using Antecedent, Behaviour, Consequence (ABC) records to evaluate the effectiveness of Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 14 strategies and use of PRN medication for residents with challenging or distressed behaviours. We noted that one member of care staff on the evening shift completed daily care records for all 23 residents and there were some discrepancies. For example we had observed a resident had vomited during the morning and although care, attention and a change of clothing had been sensitively provided, there was no mention in the person’s daily notes. Another two resident’s daily notes recorded that they had participated in the music and movement activity in the lounge, when one person had slept soundly throughout and the other person had watched passively from the dining room. The entries for the care provided at night were basic and did not appear to reflect levels of activities claimed, such as people who were restless or had wanted to get up at early hours. One person’s stated, “generally slept well all night and another the only entry, 16/4/08 “sleeping when checked,” though this person was up and dressed at 07:25am at the start of this inspection. The records meant that only limited credence could be placed on their accuracy or usefulness. We noted the positive action relating to a referral to the GP and community dietician, for investigation, support and advice for a resident with poor appetite and swallowing difficulties. The registered manager told us that the resident’s GP was only changed if their own GP was not willing to provide medical care because of geographical borders. These decisions were not recorded in care files. We have recommended that where changes have to be made, discussions and decisions be documented. Where residents do not have capacity to make their own decisions the home must involve appropriate advocacy and take account of the Mental Capacity Act. There was documentary evidence that all residents have appropriate access to dentists, opticians, chiropodists and other community services. We spoke to a district nurse who had been involved with the home for a long time. She told us she was involved with a number of residents who required dressings and usually visited at least once a week, sometimes more. She stated that the atmosphere was always “relaxed and welcoming and that the staff were caring – above and beyond duty.” She had observed that residents were treated respectfully and privacy and dignity were preserved, with residents always taken to their own rooms for dressings. They were always well presented, with small touches, pieces of jewellery such as necklaces. She stated that “the manager and staff were always helpful and the manager was excellent; very knowledgeable about residents and always with information to hand”. The Pharmacist Inspector undertook inspection of the control and management of medication within the service on 17/04/08. We identified three areas (medication procedures, medication training and medication records) that need further management to ensure the safety of medication within the home. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 15 A basic medication policy was available, however it was not detailed or specific to the service. For example, there was no information on how medication was administered, received or disposed of within the service. Of concern was the lack of any policy for medication that needed to be taken out with a resident. For example, we saw two painkillers removed from the medicine trolley and placed in a plastic envelope to be given to a relative to administer. No procedure was available for the safe handling of medication or what checks and records would need to be made. This means that it was difficult for staff to follow a working medication policy to ensure that the residents were safeguarded. The manager informed us that staff had undertaken some medication training provided by ‘Social Care Training’. It was not clear whether the training course covered all aspects of safe handling of medication. We saw no evidence of any checks on competencies of staff who administer medication and therefore to ensure the safe handling of medication within the service. The majority of medication we saw was stored safely in a locked cupboard and also within a locked medicine trolley. We saw medication stored neatly and tidily, which ensured that residents’ medication could be easily located. The room felt very warm, however there was no temperature checks to ensure that medication was stored at the correct temperature. Medication requiring refrigeration was stored in a ‘mini’ refrigerator, however the temperatures recorded by staff were not correct. For example, records showed that the temperature was 21°C, which is room temperature. Some medication, which requires special lockable storage arrangements did not meet the required legal specifications, which means that some medication was not stored correctly according to legislation. It was noted that the provider had installed a cabinet for this purpose, however it did not meet the legal requirements. The majority of the medicine records seen were documented with staff signatures to record that medication had been administered to a resident or a code was recorded to explain why medication had not been administered. It was therefore disappointing that some of the medicine records were not clear. For example, one resident was prescribed a medication to be administered every morning, however the records seen indicated that there were four days (3rd April to 6th April 2008) when the medication was not recorded as administered on the medicine record. A code ‘O’ for ‘other’ reason for not administering the medication had been documented but there was no reason given for this. The manager informed us that the medication had actually been administered to the resident but that staff had not signed the medicine chart. This means that due to the incomplete medicine records there is an increased risk of a medication error and therefore increased risk of harm to the residents’. We saw some medication records that had been altered, which meant that it was not possible to identify who had administered the medication or whether it was administered correctly. For example, we saw records had been altered Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 16 using white correction fluid and also some staff had signed for the administration of medication over the top of another staff signature. This is poor practice because inaccurate medicine records may increase the risk of a medication error. A new system for documenting the amount of medication administered was started on 10th April 2008. For example, we saw that a colour coding system, using different highlighter pens, was being used to indicate whether ‘one or two’ painkillers had been administered. This means that it was possible to check that medication had been administered according to a doctor’s instructions and therefore safeguard the resident with accurate medication information. Some medication was checked to ensure it had been administered correctly because it was available in a weekly cassette labelled with the day of the week. These checks were accurate. The service had recently started to check medication. We saw a form called ‘Resident Medication Audits’ in order to check the monthly balances of medicines, which helped to make accurate checks on medication. However not all medication could be accurately checked in this way. We saw boxes of medication that were not dated when they were opened and that the receipt of medication into the service was not always recorded. For example, we saw that an antibiotic had recently been administered, however there was no date of receipt. The pharmacy had documented on the medicine record that a quantity of 6 tablets were supplied, however there were a total of 8 staff signatures recorded for the administration of the antibiotic. This means that accurate checks on medication could not always be made and staff were not checking what they were signing on the medicine records to ensure that medication records for administration were accurate. The times of the medication administration were not evenly spaced to ensure accurate medication administration. We saw times for medication administration documented at 7am, 2pm, 6pm and 10pm, which does not ensure that medication is administered according to a doctors directions and could have possible adverse affects on the residents. Staff were observed treating residents with respect. For example staff did not rush residents with dementia when communicating, making efforts to ensure they were not excluded from conversations by ensuring they positioned themselves so eye contact could be made, giving residents time to answer questions and using gestures to help them understand. Residents were seen to be dressed appropriately for the weather and efforts have been made by staff to ensure clothing co-ordinated, again promoting residents dignity. There was also lots of appropriate banter and laughter, encouraging residents to join in conversations. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 17 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 adequate. There is some progress to make planned and spontaneous activities available on a regular basis, which would give residents improved opportunities to take advantage of and develop socially stimulating activities. The majority of residents are able to maintain good contact with family and friends. Dietary needs of residents are catered for with a balanced and varied selection of food that meets residents tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s AQAA dated 26 March 2008 stated: “What we do well: All meals are corked afresh within the home. Food. Provide good nutritional meals-ingredients bought locally. Meals prepared to residents meals. Leisure. Activities are provided. The frequency discussed with residents. Relationships. Residents are encouraged to keep contact with friends and relatives and go out with them. Religion. Residents wishes are discussed during monthly meetings. Privacy is respected, residents may meet with family/friends in privacy. Feeding. Always staff member present in dining room to assist with eating. Nutrition. Requested nutritional assessment. Treats are provided. “ Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 18 The home’s AQAA stated, “How we have improved in the last 12 months: Brought in extra activities i.e. craft sessions. Started regime of smoothies for residents who are not eating too well. Started residents monthly meetings. Started regime of home-made soups for residents not eating too well. “ We were able to confirm the accuracy of the information detailed in the AQAA, through observations, examination of records and discussions with residents, relatives, staff and the registered manager. We recommended that the registered manager consider consulting residents about transport options for outings and possibly registering people who express interest on the Ring and Ride service. This would facilitate residents to access local community amenities. Part of the anonymous complaint sent to the CSCI was that residents were being forced to get up at 5:00am. However on the day of this unannounced inspection visit there were 9 of the 23 residents up in the lounge, another person was being wheeled into the lounge. We spoke to the manager about the staff who used the wheelchair without footplates to transport the resident, and posed a hazard to the person’s feet and legs. Two residents told us they get up, washed and dressed without assistance and chose to get up early. Three members of night staff interviewed throughout the inspection told us that residents were not forced to get up, though they named 3 residents who regularly woke very early, between 4am – 5:30am and indicated they wanted to get up. We looked at the preferred rising and retiring times in their care plans and the times of rising were documented as 6am, and 7am. We advised the registered manager to review and update information as it changes so that preferences and care plans accurately reflect current needs. Night staff told us that all residents were offered a cup of tea and have their first medication of the day at around 7:00am. This means that the routines of the home were not as flexible as they could be allowing residents to get up and have breakfast at times to suit them. The majority of residents were up and having toast and cereal at 08:50am. There was no evidence to uphold the element of the complaint, though the home has agreed to change the time of the early morning medication, discussed at the previous section of this report. As part of the inspection we have talked to people about activities and we have been told that the home had generally increased the amount of activities on offer. The manager had implemented generic records for each activity and there were activity preferences recorded but not specific individualised plans or activity records on residents case files. There was evidence of entertainers brought into the home, such as singers, with references in notes of residents meetings. We spoke to the activity provider for the music and movement who had been visiting the home for about 10 years, and stated, “felt like part of the family, its very homely and outshines other homes she visits with the friendliness of staff and residents” Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 19 she went on to say, “staff do genuinely care, real interest in residents and families.” There was evidence that efforts were made to maintain contacts with residents’ families and friends. There were a number of visitors to the home during the inspection and those we spoke to were very positive about the care, staff and management. We were given the following comments from a relative who was visiting an aunt; “the home is very good, nice atmosphere and brilliant staff, with good interaction, activities provided to keep them busy.” During the tour of the home we noted that residents were encouraged to have their personal possessions around them, which was very positive. However the residents’ files sampled did not contain a list of personal possessions, or complete inventory, with signatures of residents, staff or witnesses. We recommended that all residents have up-to-date inventories of their personal possessions, which are signed dated and witnessed by staff, the resident and / or their representative. It was a positive that staff were seen sitting with residents for short periods. For example a member of staff was seen to sit with the residents after breakfast discussing the view of the music and movement, which was taking place in the adjoining room. At meal times staff were seen to offer assistance to residents when needed in a discreet way. For example if assistance was needed to cut up food they did this away from view of other residents. Some residents with dementia were not able to use cutlery. Staff were aware of these residents and did not take away their independence in this area but allowed them the time to do this themselves, promoting independence. The home still uses written menus; lounge detailing a choice of meals at breakfast, lunch and tea but not supper. Although we noted that the cook went to each resident to ask what they wanted to eat for the cooked lunch, and offered both choices to a resident who could not make a decision, it is strongly recommended that further work be undertaken to provide this information in large print, picture format, as residents with dementia may not be able to read this in its present format. The cook made efforts to communicate with people with dementia, kneeling by the side of residents who were sitting down in order to maintain contact, talking at a level and pace that encouraged residents to join in the conversation. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 20 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 home has an accessible complaints procedure, which means that concerns are listened to and action is taken to look into them, and there are systems to record any investigations and outcomes. The home has arrangements for protecting residents and policies, procedures, guidance available. Although staff have received training to provide better safeguards for residents from potential abuse, there is not sufficient awareness and understanding of the multi-agency safeguarding procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s AQAA submitted on 26 March 2008 states, “What we do well: We listen to residents/ families. We talk to residents and families. We have a clear accessible complaints procedure and all residents have a copy plus copy on display in hallway. Any allegations of abuse will be taken on board and handled in the correct manner. The home does not handle any resident’s monies. Make sure everyone knows who to speak to if they have a problem.” The AQAA stated, “How we have improved in the last 12 months: Staff training in abuse completed and to be undertaken yearly. Compiled complaints pro forma. Monthly residents meetings to encourage residents to voice any worries. Updated complaints procedure.” Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 21 The home has complaints procedure displayed in various areas throughout the home. The previous recommendation that the complaints procedure should be produced in alternative formats suitable for residents, such as large print, has now been put in place. The AQAA indicated that there had not been any complaints or allegations made to the home. However an anonymous complaint had been received at the CSCI office, with allegations of poor practice, which have partly investigated as part of this unannounced key inspection. The complainant had also made two serious allegations but without detailed information, which have been referred to the Local Authority safeguarding procedures to be assessed at a multi-agency strategy meeting, following the key inspection. A large number of CSCI surveys were left at the home for people to complete with their views or any other information they wish to submit to the CSCI. At the date of this report 3 surveys have been received from residents / relatives and 3 completed surveys from staff with positive responses and constructive suggestions. As part of this inspection visit we have interviewed 8 members of staff, an ex member of staff, 2 relatives, a district nurse and another visitor and no concerns have been expressed, only positive comments made. The home had a copy of the multi-agency procedure ‘Safeguard & Protect’, with guidance for the safeguarding of adults. Discussions with residents, relatives, the district nurse and staff demonstrated that they were aware of how to raise concerns and make complaints and would do so if necessary. The home has provided all staff with adult protection training from a training organisation, which had issued certificates with an annual expiry date. Staff spoken to could not recall whether the training included reference to the Local Authority Safeguard and Protect procedure. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 22 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, 21, 24, 26 Quality in this outcome area is good. The significant and positive changes to the décor and furnishings contribute to creating a pleasing and pleasant environment for residents to live in. Some of the laundry processes do not promote good infection control. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s AQAA submitted on 26 March 2008 states, “What we do well: Keep the home clean, odour free, warm, well maintained and decorated. The home is not allowed to be left in a rundown state, the standards of décor are frequently monitored and constantly maintained. (Where applicable). No smoking policy. The home is well ventilated and light. All carpets are correctly fitted and clean. Maintain all equipment-service. Manual handling aids are provided. All rooms are fitted to a high standard. Open house for visiting.” Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 23 The AQAA stated, “How we have improved in the last 12 months: “Replaced conservatory roof and installed opening windows. Drive tarmaced. Ramp to get up step-for wheelchair. Wet room. En-suite on to double room. Replaced toilets. Decorated. Re-carpeted where needed. Hoist provided. Provided hands-free phone to enable residents to use the phone easier.” We undertook a tour of the premises, talked to staff and residents and examined documentation. There was evidence, which confirmed the information provided in the home’s AQAA. The premises were homely and domestic in style, with a bright, cheerful and well maintained interior. There were attractive gardens and garden furniture for the residents comfort and enjoyment, though the rear and side gardens would have benefited from more attention. The tour of the building identified that improvements claimed in the AQAA had been made and a programme of redecoration and refurbishment was in progress. Residents told us that that they liked living here and are comfortable. The sample of residents bedrooms viewed were well maintained and individually decorated providing pleasant personal living space, especially in the new wing. These bedrooms have en suite facilities and patio windows onto the pleasant landscaped and paved area of garden. One bedroom on the first floor had a distinctive malodour and the registered persons agreed to resolve this, replacing the floor covering if necessary. We have strongly advised that advice and reassessments be requested from the continence service, especially relating to the use of ‘old style’ draw sheets. A double bedroom on the first floor only has commode chairs, neither resident has been provided with a comfortable armchair in their bedroom. Their preferences must be discussed with them and recorded. The window in bedroom 10 had frosted glass; the registered manager informed us that this was put in place after objections from previous neighbours. This must be reviewed and discussed with the current resident, their relatives / advocates and the Regional Registration Team at the CSCI office, Birmingham. The first floor bathroom has been completed renovated to provide a walk in shower. We advised that this room be completed with a mirror so that residents can do as much as possible independently. The kitchen area is generally well organised, clean and tidy and food safety had been improved. The home had the recommended guidance from Dudley MBC Environmental Services, the manual Safer Food, Safer Business, though not all records were completed. The refurbished laundry had been completed, with new more effective equipment but as indicated in the anonymous complaint the kitchen and dining room linen was being washed together with towels, a nightdress and a sock. The home has a copy of the latest guidance from the DOH (Department of Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 24 Health), ‘Essential Steps’ for infection control, however this was not in use. The registered persons immediately agreed to implement and monitor more rigorous infection control procedures, including a written laundry procedure. The laundry area contained extraneous items, causing clutter, which would impede good infection control measures. The home does not have fully effective documented, monitored cleaning schedules for the kitchen and laundry. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 25 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, 30 Quality in this outcome area is adequate. The staffing levels provide adequate levels of care and support, though the lack of designated roles to be responsible in the manager’s absence poses the risk that residents may not have all care, support and need for stimulation met. The staff recruitment processes do not entirely minimise the potential for residents to be exposed to risks of harm. The registered persons have invested in training to develop staff but evidence of the training providers competence is lacking. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s AQAA submitted on 26 March 2008 states, “What we do well: Staff are highly trained well motivated. The staff are paid well above national minimum wage. Staff receive all allowances i.e. 3 paid training days. The staff receive full holiday allowances.” The AQAA stated, “How we have improved in the last 12 months: increased staff training by 33 .” The staffing information contained in the AQAA indicated, “Number of staff 24, 5 full time carers, 15 part time carers, 6 other staff and for the week of 9-5/03/08 414.5 care hours for personal care were provided. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 26 There were 23 residents accommodated at the home, with a variety of dependency levels and diverse needs. Following discussions at the previous inspection in April 2007 the registered manager agreed to regularly review residents dependencies and occupancy levels, and review staffing levels, making appropriate adjustments, with the use of a recognised staffing tool, such as the Department of Health Residential Forum staffing Tool. A requirement was made for a staffing proposal to be forwarded to the CSCI for consideration. These actions remain outstanding. An example provided from the Residential Forum Staffing Tool indicated that the home should be provided with 511.78 dedicated care hours each week, which would include 19.14 care hours dedicated for activities. We were told that the registered manager, Kathleen Oakley had been allocated the majority of her time for managerial hours, with a small number of hours dedicated to covering any care staff shortfalls. Kevin Franklin continued to undertake the administration and business tasks. On the day of this inspection visit the registered manager was part of the 4 care staff on duty from 08:00 till 13:30/14:00 hours. There were 3 carers from 14:00 until 22:00 hours. During the night there were 2 waking staff on duty. The cook worked from 09:00 to 14:30 hours during the weekdays only, and domestic staff were employed to cover 7 days each week from 07:00 till 12:00 hours. The care staff continued to undertake catering and laundry duties during the afternoons, which continued to deplete care hours available for residents. Though the SOFI undertaken as part of this inspection recorded mainly positive staff interactions; and there was only a 15 minute period without any staff interaction out of the 110 minutes of observations, the registered manager and registered provider also gave support during this time. There were also a small number of comments, that more staff time to talk to residents or do individual activities would be something the home could do better. We were told that there was no change to the structure of the staff team: registered proprietors, registered manager and administrator, 19 care staff and 5 ancillary staff. The home did not have designated senior staff for supervisory tasks to be delegated to, and though we were told there were named designated persons in charge of the home, on a day-to-day basis when the manager is off duty, there was no documentary evidence on the staff rota. The registered manager told us that it was generally the member of care staff who has been at the home longest. This situation is not satisfactory to ensure the health, well being and safety of the residents. Assessment of the information on the AQAA, staff files and staffing rotas during the visit show that four staff have left the homes employ since the last inspection visit in April 2007. The staff have all resigned for valid reasons, such as change of career, travelling abroad and health concerns. An ex-member of staff visited the home during this inspection, with magazines for residents and Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 27 to see ex-colleagues. This person willingly gave us an interview and expressed very positive views of her experiences at the home, though she stated she had sustained an injury during first aid training, which was the only record of a staff accident at the home. There was evidence that the ratio of care staff with an NVQ 2 care award had increased from the minimum ratio of 50 to 75 , with another 6 staff undertaking the award. We have examined 2 of the 4 new staff personnel files in detail and looked at 2 in less depth. Generally files indicated that recruitment procedures were followed with essential recruitment checks and clearances in place, although there are still unexplained gaps in employment histories on application forms. Examples are that one person had not completed the homes application form with starting or leaving dates of previous employment, therefore this does not constitute a full employment history and any gaps would not be noticed. Another new employee had gaps of 5-6 months in their employment history and the home had not sought an explanation. A third file had a reference indicating the person was an employee, though this was not the referee documented, nor was the employment recorded as part the employment history on the application form. Two references were not specifically addressed to the management of Rosemary Retirement Home and had no evidence of their authenticity. One person was employed on a POVA first basis for two weeks and the registered manager acknowledged that there was no written risk assessment in place or notification to the CSCI. The homes training needs analysis and training plan and individual staff training profiles were in place and though these show commitment to staff training and development, there was no evidence of the competence of the trainer, who had provided training for every topic. During interviews and informal discussions staff were willing to answer questions openly and they were knowledgeable about residents needs and how to meet them. There was a warm rapport with both residents and visitors. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37, 38 Quality in this outcome area is adequate. The registered manager has not entirely utilised the opportunities to develop effective leadership, direction, and ensure there is good communication. There are now systems for resident consultation at Rosemary Retirement Home, and there is some evidence that indicates that efforts are made to ensure that residents’ views are sought and acted upon. The standard of record keeping and health and safety compliance has not sufficiently improved to reduce the potential for risks of harm for residents. The management of medication, infection control and health and safety does not entirely safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s AQAA submitted on 26 March 2008 states, “What we do well: Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 29 Keep the home running profitably so as to enable us to have an ongoing fund readily available to fund the expected and unexpected. Ensure that all paperwork is up-to-date and completed correctly or making sure that all paperwork is implemented in the appropriate manner enabling us to provide the ultimate direct care.” The AQAA stated, “How we have improved in the last 12 months: Increased volume of paperwork. The more vigilant on completing paperwork and have passed this on to staff. Have made everyone aware of the importance of paperwork no matter how trivial this may appear.” Kathleen Oakley was the registered manager at Rosemary Retirement Home. She has worked at the home for many years and we were told that she had been allocated dedicated managerial hours to implement improvements to demonstrate compliance with the Care Homes. Although she had made progress with some improvements she still needed dedicated time to devote to monitoring care delivery and developing the care staff. She had a relevant job description and had taken overall managerial responsibility for the running of the home, with assistance from the homes administrator, Kevin Franklin. At the previous inspection in April 2007 we were told that the registered manager was continuing her personal development, due to undertake the Registered Managers Award (RMA), which should have commenced on 4 August 2007, with Dudley College. She had informed us that she had hoped to achieve the award within 12 months. However she had not registered and at this visit told us she would be registering with a different training provider. The manager must develop her managerial skills to effectively provide the quality care delivery required to ensure residents health, well being and safety. We have discussed the need for accurate records with the registered persons, not as an end in themselves but as essential information and protection for residents, demonstrating that everyone who needed to know had awareness of each persons care and support required and that it had been provided to a safe and satisfactory level. At the previous inspection the home had purchased a quality assurance system, Mulberry House policies and procedures and limited progress was being made with implementation. The system, policies and procedures were not fully implemented at this inspection. We have discussion the need to provide fuller details, particularly evidence in the home’s AQAA (Annual Quality Assurance Assessment), which the CSCI used to evaluate the home’s ability to assess its own performance, and set goals for improved quality outcomes for residents. Though the registered manager had circulated the homes own questionnaires the collated results with feedback from residents, visitors, and other stakeholders such as GPs and Social Workers were not yet available. There were minutes of two staff meetings in the past 12 months. We have advised that there should be a Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 30 minimum of 6 staff meetings annually with a planned schedule to encourage attendance. Monthly residents meeting have taken place chaired by a member of staff, which was positive. The registered manager had commenced a structured formal staff supervision system, though she had not achieved the minimum of 6 recorded one-to-one meetings with each member of staff, each year. As discussed at the inspection in April 2007, we have again strongly advised that the home needs to consider senior care assistants as part of the staffing structure to make the supervision and development of staff workable. We were told that the home was not responsible for residents finances and did not hold any monies on their behalf. Invoices were sent to families or Dudley MBC monthly for any purchases such as hairdressing or chiropody. There were some further improvements to records, which included the comprehensive pre-admission proformas, care plans, and daily records, though there were still records requiring further improvement such as daily records, risk assessments, and particularly, medication records and staff records. The random assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. The home had obtained a Legionella risk assessment and had an Asbestos risk assessment. There was evidence that mandatory training is being sourced and provided for all staff on an on-going basis, though the competence of the trainer had not been verified. The training certificates indicated that training in all areas was required annually, despite good practice guidance from organisations such as ROSPA that accredited moving and handling training could be valid for up to three years. We have examined accident records and there were 103 recorded accidents involving residents since April 2007. The registered manager had introduced a system for auditing, analysing and evaluating accidents involving residents. This demonstrated effective measures, for example two residents had been referred to GP’s for medication reviews and one person had been referred to the stroke team. We have recommended that the analysis would have added benefits if it were expanded to include more information such as times of accidents. Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 31 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A 2 2 2 Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement To ensure daily notes reflect progress or otherwise related to goals and needs identified in the care plan. This will ensure that residents health and welfare needs are properly met (Timescale of 01/06/07 Not Met) Timescale for action 01/06/08 2. OP8 13(1) To ensure that the all health care 01/06/08 risk assessments and care plans reflect all changes to residents’ health and needs. This will ensure care for residents’ health and well being is properly provided at all times 1) The registered persons must 01/06/08 ensure that all care staff who administer medication have received training on the safe handling of medicines (and provide documentary evidence of the current training providers accreditation). This will ensure that the people who use the service are administered medication from trained and competent staff. DS0000024975.V362302.R01.S.doc Version 5.2 Page 33 3. OP9 13(2) Rosemary Retirement Home (Timescale of 01/11/06 and 01/06/07 Not Met) 2) The medicine policy must be reviewed and updated in order to ensure it is specific to the service and that the health and welfare of service users taking medication are safeguarded. (Timescale of 01/11/06 and 01/06/07 Not Met) 3) To ensure staff signatures are obtained to demonstrate awareness and compliance with medication policy and procedures. This will ensure service users are safeguarded by staff who are knowledgeable and competent (Timescale of 01/06/07 Not Met) 4) To ensure that staff record variable dosages of medication administered on MAR sheets, for example one tablet or two (Timescale of 01/11/06 and 01/06/07 Not Met) 4. OP9 13(2) 1) Medicine records for the administration of medication must document what has been administered or record a reason why it was not administered in order to ensure that the people who use the service are safeguarded. 2) Receipt of medication records must be available in order that safe levels of medication are retained in the home to ensure that the health and welfare of people are safeguarded. (Timescale of 01/11/06 Not Met) 01/06/08 Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 34 3) The service must ensure that medication is administered at equally spaced intervals or in accordance with a doctor’s instruction to ensure that medication is administered to residents at the correct times and ensure that their health and welfare needs are met. 5. OP26 13(3) To devise and implement documented cleaning schedules for the Kitchen and laundry. This will ensure that residents are protected from cross contamination and risk of infections. (Timescale of 01/06/07 Not Met) The Registered persons must ensure that there are adequate numbers suitably qualified, competent, and experienced staff, with a designated suitably qualified, competent, and experienced person, to be responsible for the home at all times to promote and make proper provision for the health and welfare of the residents. 1) To ensure any gaps in employment history are fully explored and reasons documented and checked wherever possible (Timescale of 01/07/07 Not Met) 2) To check the authenticity of references, ensuring that there is a reference from the last care employer or documenting reason why not possible and request that referees print their name and use company paper or Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 35 01/06/08 6. OP27 18(1)(a) 01/06/08 7. OP29 19(1) 17(2) Schedules 2 and 4 01/06/08 company stamp (Timescale of 01/06/07 Not Met) 3) To ensure that there is a written risk assessment in place for any person employed on a POVA first basis to protect and safeguard residents. 8. OP36 18(1))(c) To progress the implementation of the staff supervision system, ensuring that each member of staff has a minimum 6 formal recorded supervision sessions in each 12 months. This will ensure residents’ health and well being and safety is promoted by well trained and supported staff (Timescale of 01/07/07 Not Met) 01/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations It is strongly recommended that the contract / terms and conditions be reviewed taking account of the revisions to the Care Homes Regulation 5 and the publication from the Office of Fair Trading relating to Contracts and terms & conditions in Care Homes That discussions about changes to resident’s GP’s be documented as part of their care records 1) A system should be introduced which demonstrates that medication is stored at a safe temperature in order to ensure that people who use the service are protected from harm. DS0000024975.V362302.R01.S.doc Version 5.2 Page 36 2. 3. OP8 OP9 Rosemary Retirement Home 2) Suitable provision must be made for the safe storage of controlled drugs under the Misuse of Drugs (Safe storage) regulations 1973 as amended. 3) A system should be introduced to ensure that accurate medicine audits can be done and check that people who use the service have been administered medication according to the directions of a General Practitioner. 4. OP12 That a structured weekly programme be devised and displayed in appropriate formats to encourage participation and individual weekly activity planners be introduced for each person to record planned and spontaneous activities, refusals and evaluation of activities offered, ensuring records accurately reflect participation (or none) That each residents property inventory be fully completed on admission with clothing, furniture, valuables, hearing aids etc. and thereafter kept up to date signed and dated by staff, resident and / or relative. It is recommended that menus are further developed and displayed in formats suitable to the residents capabilities and include suppertime options. That staff signatures are obtained to demonstrate that they have read and have an awareness of the homes and the multi-agency procedures for the protection of vulnerable adults Safeguard & Protect – Not Met That behaviour care plans be expanded with fuller information to guide staff to understand behaviour triggers for individual residents and how to manage behaviour that challenges, such as agitation, wandering etc. That a mirror be provided in the new walk in shower 1) That room audits identify whether all facilities to meet National Minimum Standard 24 for Older People have been provided and signed discussions and agreements be documented on each residents file 2) That at least one comfortable chair be provided for each resident occupying the shared double bedroom 3) That documented discussions take place regarding the Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 37 5. OP14 6. OP15 7. OP18 8. OP18 9. 10. OP21 OP24 frosted glass main window in bedroom 10, with proposals submitted to the CSCI for consideration 4) That appropriate alternatives to the ‘old’ style drawsheets be explored with the continence service and more effective and comfortable continence aids be provided, such as kylie sheets 11. OP26 That any malodour in the home be explored and eradicated to maintain the home to be free from any malodours at all times 1) That the registered persons ensure that all staff are familiar with the publication from the DoH ‘Essential Steps’ for infection control 2) That a comprehensive laundry procedure be devised, implemented and monitored 3) That all extraneous items be removed from the laundry 4) That washing is appropriately segregated at all times, with items from the kitchen laundered separately in compliance with Food Safety Regulations 13. OP30 It is strongly recommended that the registered persons ensure that the home has documentary evidence of any training provider’s accreditation and competence to deliver training to staff That all staff receive training relating to the Mental Capacity Act and have an awareness of its implications for all aspects of their work. That the registered manager completes the Registered Managers Award, within an identified timescale i.e. with 12 months (April 2009) That a documented annual schedule of supervision sessions be devised and displayed to encourage participation That a checklist matrix be used to record and monitor personal care provided – Not Met That staff using wheelchairs to transport residents make sure that the footplates are in place and used correctly, unless there is a documented risk assessment in place for DS0000024975.V362302.R01.S.doc Version 5.2 Page 38 12. OP26 14. OP30 15. OP31 16. OP36 17. 18. OP37 OP38 Rosemary Retirement Home residents capable of understanding risks and giving informed consent 19. OP38 That the registered persons expand the documented accident analysis to more clearly identify times, trends and record remedial / control measures That the engineers from the company used to monitor water temperatures be required to record remedial work to rectify excessive water temperatures Rosemary Retirement Home DS0000024975.V362302.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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