Inspection on 10/01/06 for Rosemeadow Residential Home

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rosemeadow Residential Home 09/04/08

Rosemeadow Residential Home 24/04/07

Rosemeadow Residential Home 26/04/06

Rosemeadow Residential Home 02/09/05

Rosemeadow Residential Home 01/03/05

Rosemeadow Residential Home 19/07/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosemeadow Residential Home 119 Station Road Misterton Doncaster South Yorkshire DN10 4DG Lead Inspector Jayne Hilton Unannounced Inspection 10th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 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. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rosemeadow Residential Home Address 119 Station Road Misterton Doncaster South Yorkshire DN10 4DG 01427 891190 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) Joseph Clayton Mrs Shirley Ann Moody Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd September 2005 Brief Description of the Service: Rosemeadow Care Home is an adapted family home set within large enclosed gardens. The house retains many of its original features making residents rooms very individual. Situated within a rural area, there is access by public transport to local towns. There is a stair lift installed and hand rails fitted to assist with mobility problems. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Inspector Jayne Hilton undertook the unannounced inspection on 10th January 2006 from 9.30am to 2pm. The methodology used for the visit included the assessment of the Statement of Purpose and associated documentation submitted to CSCI. A sample of records were examined, a part tour of the premises and four service users and two staff were spoken with as well as the manager. The manager had been working since the last inspection to finalise the assessment and care plan documentation and a sample examination of these provided evidence that clear progress on these had been made. Residents looked well cared for and no complaints or issues of concern have been notified to the Commission at this time. Many of the standards assessed are not met but the outcome of the care that residents receive gave no cause for concern, indeed the care and support provided was seen to be and confirmed by the residents to be very good. The Recruitment practices were found to be in breach of regulation and an immediate requirement was set in relation to this. The Registered Provider must obligate his responsibilities under Regulation 26. Please note. An Action Plan for this inspection report must be returned to CSCI within 28 days of its receipt. What the service does well: Residents feel “the home is one of the best” and feel pleased that they have been able to get a place there. Provides a very homely atmosphere in which residents are treated with respect by staff that know them well and ensure that they receive the support they require to live as independently as possible. The view of the residents spoken with was that the care they receive was Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 6 excellent. From observation it was clear that people were cared for sensitively and respectfully. The service users health, personal and social care needs are set out in an individual plan of care. Medication is generally well managed. Service users feel they are treated with respect and their right to privacy is upheld. Service users needs are assessed and they feel their needs are being met. Service users find the lifestyle experienced in the home matches their expectations and satisfies their social, cultural, religious and recreational interests and generally their preferences and choice is respected. They can maintain contact with family, friends and representatives and the local community as they wish. Service users enjoy their food. A good level of NVQ training has been provided. The manager has recently been registered with CSCI. The home is generally run in the best interests of service users. What has improved since the last inspection? A Statement of Purpose and Service User Guide has been devised. Care plans have been reviewed and the necessary improvements have been generally made in recording all of the needs of the resident. The complaints policy has been reviewed to ensure that people are fully informed about how they can complain. Policies are in place for dealing with abuse and whistle blowing Controls are now in place for the prevention of legionella An additional single en-suite room is now almost completed. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 7 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. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 Prospective service users do not have the full information to make an informed choice about where they live. Service users needs are assessed and they feel their needs are being met. EVIDENCE: A Statement of Purpose and Service User Guide has been produced but were assessed as needing some amendment to meet the requirements of the regulation fully. • • • Include the background and experience of the Registered Provider and Registered manager Include more information about the training provision of staff Include the registration category for the home and remove any misleading information regarding physical; disability and mental impairment, as the home is not registered to admit service users with these needs. DS0000061213.V271758.R01.S.doc Version 5.0 Page 10 Rosemeadow Residential Home • • • • • • • Be clear that nursing is not provided but include how any nursing needs will be addressed Expand the information on activities and who is responsible. Explain how service users and relatives will be consulted. Expand on how contact between service users and their relatives etc will be maintained [i.e. telephone access visitors policy etc] Detail the size of each bedroom Identify how physiotherapists etc will be accessed. Include information whether emergency admissions can be taken and what criteria will be needed should this be the case. Assessments were in place and almost meet the standard, Foot care needs to be included and the it is recommended that nutritional, tissue viability, mobility, infection control and dependency risk assessment tools are used in conjunction with this. The issue of bedroom door keys and for lockable facilities should also be included. There was no evidence that service users are provided with written confirmation that the home can meet their needs and this is required by regulation. The assessment and care plan documentation need to contain more detail of service users wishes and preferences and how the service users needs will be met by staff. The Statement of Purpose stated that day care is provided and the manager reported that this is provided for one service user. The CSCI need to be informed about this and the provider must ensure that there is sufficient communal day space to facilitate this service and that staffing levels are adjusted accordingly as necessary. Four service users were spoken with and they praised the care at the home highly and felt their needs were being met. Residents feel “the home is one of the best” and feel pleased that they have been able to get a place there. Provides a very homely atmosphere in which residents are treated with respect by staff that know them well and ensure that they receive the support they Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 11 require to live as independently as possible. The view of the residents spoken with was that the care they receive was excellent. From observation it was clear that people were cared for sensitively and respectfully. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The service users health, personal and social care needs are set out in an individual plan of care. Medication is generally well managed however there are some areas to address to meet the requirements of the Medicines Act. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Care plan s are now in place and meet the minimum standard, however further detail would improve these. There was evidence that the plans were drawn up with the involvement of the resident or their relatives, however the manager has had some difficulties obtaining signatures for all. It is recommended that where service users or their relatives do not wish to be involved then a declaration and signature stating this should be obtained. The records held contain some good systems of recording information such as Doctor’s visits, night care plans and bereavement details. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 13 Medicine management was assessed and overall was satisfactory, however an omission of medication was observed not to have been documented as to the reason why. A medicines trolley is used and is kept in a locked cupboard when not in use, storage temperatures of medication, was not being taken and this is required. Medication record sheets were neat and tidy and contained sample signatures of staff and photographs of service users. Eye drops were stored appropriately however care must be taken to ensure that staff are aware of whether the prescribes eye drops need to be stored in a fridge and informed of the potential risk and consequences of storing these incorrectly. Staff are currently undertaking a medicine management-training plan, which is accredited. The policies and procedures for the safe handling of medicines need to be further developed in line with the medicines Act. The manager was advised to obtain a copy of the Royal pharmaceutical society guidance for the administration of medicines in care homes. The drug error policy needs to be separated out from the information about general poisoning and inform staff of appropriate, easy to access action should a drug error occur. A system should be in place for the stock rotation of dressings and creams. At the last inspection staff were advised to ensure that any softclix blood testing pens must be used for individuals only as per Department of Health instruction. [This issue was not assessed at this inspection and is therefore carried forward to be assessed at the next visit.] Residents all spoke of how good the staff were and how their privacy and dignity was maintained. It is recommended that service users are asked if they wish to have privacy blinds or nets fitted and that this is documented within the care plan. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users find the lifestyle experienced in the home matches their expectations and satisfies their social, cultural, religious and recreational interests and generally their preferences and choice is respected. They can maintain contact with family, friends and representatives and the local community as they wish. Service users enjoy their food. EVIDENCE: There was evidence of a range of activities being provided but there was no evidence of who had actually participated or who had been offered and refused. An activities co-ordinator is employed for two and a half hours a week. The Registered provider needs to provide evidence that the activities person has undergone the relevant recruitment checks. Trips out are arranged periodically and staff cars are used, the manager reported that staff cars are appropriately insured for this purpose. The Statement of purpose needs to inform service users how they will be supported to maintain family contact etc. The statement of purpose informs the reader that meals can be ordered at a cost for visiting relatives. Care plans and service users confirmed that they could make choices and decisions about their daily living routines such as going to bed and when they Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 15 get up. Drinks are supplied frequently through the day and service users confirmed they could request drinks at any time. The manager and the cook prepare a weekly menu but this did not always have a second option on offer. Records should be kept of food choices and the menu reviewed and developed with service users. It was recommended that a service users survey be used to focus on the subject and to obtain service users views. Service users informed the inspector that they enjoyed the food and that they were satisfied with the quality and quality of food provided. They said that it was sometimes served a little too hot. Service users also said that they don’t get much variation in food and that supper is only usually a couple of biscuits and milky drink but that it was served at 7.30pm and where service users don’t eat breakfast until 9am this seems a little too long to go between meals. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users feel confident to make any complaints. The homes own policies for safeguarding adults does not reflect the local guidelines and may not provide a robust system for ensuring that staff are aware of the appropriate action to take in the event of ant suspicion or allegation of abuse. EVIDENCE: The complaints procedure has been reviewed as required at the last inspection and although the statement of purpose informs service users that complaints will be responded to within 28 days the actual written procedure does not. The procedure needs to specify that complaints will be responded to in 28days. A formal system needs to be implemented to record complaints. Service users spoken with stated that they were confident about making any complaints should they have anything to complain about, they added that if they had any grumbles these are addressed promptly. The previous two inspections required that the provider obtain a copy of the Nottingham Vulnerable Adults procedure and the website address was provided by the inspector. This has not been obtained and again was not available. At this inspection the inspector gave the manager details of the Adult Protection Unit to obtain one. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 17 There was however a policy in place for safeguarding adults and a whistle blowing policy but the information in the Statement of Purpose and in discussion with the manager it was clear that she was not aware of the current requirements for reporting and referring to safeguarding adults. This is outstanding. Training has been provided in vulnerable Adults and abuse awareness. There have been no recorded complaints or adult protection investigations since the last inspection. A policy is in place for restraint and the manager is to ensure risk assessments are completed for the use of bedrails and confirms service users and relatives will be given full information about the risks involved before being asked to sign to the agreement of their use. In the Statement of purpose a statement is made for dealing with service users who may be aggressive, whilst the information contained is acceptable it does not cover strategies to be implemented where service users present challenging behaviour or address the training needs of staff. The systems in place for handling service users small cash amounts are not fully robust and these must be addressed to ensure service users are fully protected from potential financial abuse. [See Standard 35] Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 A comfortable, clean and generally safe standard of accommodation is provided for service users. Refurbishment and repairs are ongoing. Essential equipment for the residents is in place to meet their needs. EVIDENCE: The home was clean and warm. There was no malodour. The registered provider has submitted plans to extend and refurbish the original accommodation. The building has a number of outstanding repairs and decorating needs that will be rectified during the proposed building work. An application has been submitted to the Commission for Social Care Inspection for one additional room and work on the en-suite has now almost been completed. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 19 The present accommodation is safe and well maintained but there are some areas, which require re-decoration. The kitchen floor covering is unsafe as there are several ripples/raised areas. This must be made safe/replaced Individual residents rooms were well appointed, they were personalised and provided a safe environment with all appropriate safeguards in place. Rooms are lockable and residents can be issued with a key to their door. There are call bells fitted throughout the home. Assisted bathing is provided via hydraulic hoists. Staff have appropriate moving and handling equipment in place. The gardens are accessible and provide seating areas. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The current staffing levels do not meet the required minimum of hours; therefore this may compromises the attention service users receive. The homes recruitment practices are in breach of the legislative requirements and therefore this may compromise the safety of service users. A good level of NVQ training has been provided, however more evidence is needed of other mandatory training provision to assess whether staff are sufficiently competent to do their jobs. EVIDENCE: The staffing rotas indicated two staff on each shift and one sleep in and one awake at night. The total number of care hours only equates to 196 hours and therefore falls below the required minimum care hours of 210 hours. Care staff are also expected to undertake some domestic and laundry duties and this means that staff are taken from care duties. Four service users require assistance with mobility and therefore service users may be put at risk if only one staff member is available when the other is engaged in the laundry room etc. The manager works supernumery, which is appropriate. Catering hours exceed the minimum standard at 35 hours, but the domestic/laundry hours are in deficit of three hours as only twenty-one hours are provided instead of the required twenty-four. Service users reported that they sometimes have to wait to be assisted for example when wanting to go to bed, due to staff not always being available. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 21 They acknowledge that staff work hard and did not wish to criticise the service or their kindness but felt that more staff were needed at times. A staffing review is therefore required to ensure that service users needs are fully met and that their safety is not compromised. 50 of staff have achieved NVQ level 2. Staff confirmed they had been issued with a copy of the General Social Care Councils Code of Conduct booklet and evidence of this was seen in the home. Staff meetings are held but minutes of these were not examined. A sample of staff personal files were examined and evidenced that recruitment practices were in breach, Staff had been allowed to start work prior to the necessary checks for POVA and CRB’s being returned. This practice must cease immediately. Other staff personal information was in place and the staff personal files well organised. The training details of staff were difficult to assess however and a full overview of staff training undertaken is needed. The manager must provide evidence that all staff have undertaken the required training in Fire safety, manual handling, and food hygiene, first aid and infection control. Some certificates were seen for fire safety but not for all of the staff team. Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 36, 37, 38 The manager has recently been registered with CSCI. The home is generally run in the best interests of service users but further improvements are needed. Service users financial interests are not fully safeguarded and improved systems are required. Staff are not yet being appropriately supervised and not all record keeping met with the regulations. Improved practices are required to ensure service users health safety and welfare is fully promoted and protected. EVIDENCE: The manager has recently been registered with CSCI and has almost completed the registered managers award. Staff reported that the management of the home is much improved and that the manager is open to ideas and is approachable. There was evidence of quality monitoring in the form of service user surveys, however this need to be further developed to include service user/relative Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 23 meetings and audits. The provider is visits several times a week but is not undertaking regulation 26 reports and this is required, copies of the monthly reports need to be held in the home for inspection. Records of service users finances were examined and were observed to be neat. Secure facilities are provided for the safekeeping of valuables on service users behalf but receipts are not being issued for this. There was evidence of a receipt for purchases made on behalf of a service user who had been sent money for Christmas but the cash had not been entered or witnessed on the service users transaction sheet. Policies and procedures are needed to ensure service users financial interests are safeguarded and that staff are fully aware of the correct procedures. No formal supervision is taking place currently but the manager reported this would be implemented shortly. The manager was not aware of notifications under regulation 37 needing to be sent to CSCI and this must be implemented promptly and copies are to be kept in the home. Water outlet temperatures need to be taken and documented and the emergency lighting tests should be recorded monthly. Fire drills need to be documented and who took part three monthly. Care plans are stored securely. The health and safety poster was displayed and completed appropriately. Kitchen records were satisfactory and food stored appropriately and date labelled on opening. There was no fire safety risk assessment inn place and this must be undertaken promptly and include the risk of the open fire. [Staff need to ensure the guard is secured at al times. Generic risk assessments need to be devised for all safe working practices. Cleaning items were left on top of the medicines trolley, which is not acceptable. There was no evidence of electric circuit testing and annual gas safety certificate. Portable appliance records were in place. A system is in place for the prevention of legionella. Staff confirmed ample supplies of protective aprons and gloves and COSHH [Control of substances hazardous to health] data sheets were in place Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 1 2 2 Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5 Requirement Ensure the Statement of Purpose and Service User Guides are amended and issued as required by regulation. Provide service users with Written confirmation that the home can meet their assessed needs Provide CSCI with details of the day care provision and confirm that the home has sufficient communal day space and staffing to accommodate this Ensure the reason for any omission of administration of prescribed medication is fully documented. Ensure eye drops are date when opened. Ensure medication is stored at a safe temperature Review policies and procedures for the management of medication to ensure compliance with the Medicines Act. Timescale for action 30/03/06 2 OP3 14 30/03/06 3 OP3 14,15,23 28/02/06 4 OP9 12,13,16 30/03/06 Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 26 Implement a clear policy for the event of drug error. The Registered Person must ensure that the homes policies and practices relfect the Department of Health Guidance on the use of Softclix devices for blood testing, ensuring that this equipment is used for individual use only and not for any other person (regardless of the change of needle) [C/F from the last inspection as not assessed] 5 OP15 12,13,16, 17 Ensure records are held in relation to food choices of service users and in sufficient detail for the inspector to assess if service users are receiving adequate diet/nutrition The Registered Person must ensure that the homes policy on dealing with abuse reflects the Nottingham Adult Protection Policy. PREVIOUS TIMESCALE OF 01/04/05 and 31/1/205 NOT MET. Extension permitted due to some improvement in homes own procedures. Ensure appropriate systems are in place to protect service users from financial abuse And for dealing with challenging behaviour. Make safe/replace the kitchen floor covering Review the staffing requirements of the home as specified in the report to ensure a minimum 210 care hours are provided. [No domestic hours or catering hours can be included in this calculation. Where care staff are DS0000061213.V271758.R01.S.doc 30/03/06 6 OP18 12,13 30/03/06 7 OP18 12,13, 17,18 30/03/06 8 9 OP19 OP27 16,23 12, 13,18 28/02/06 30/03/06 Rosemeadow Residential Home Version 5.0 Page 27 10 OP29 7,9,19 expected to undertake these duties supplementary hours must be provided above 210.] 10/01/06 Newly employed staff must not be permitted to commence work duties prior to the receipt of a satisfactory POVA check, a satisfactory Criminal Records Disclosure and two satisfactory written references. Regulation 7,9,19. Immediate. In emergencies staff may be permitted to work with the receipt of a satisfactory POVA First check but must be appropriately supervised at all times until the criminal records disclosure is received. Any staff working at the home without receipt of the necessary checks must not be allowed to work without the appropriate documentation being received. Provide evidence of all staff training to CSCI. 11 OP30 18 30/03/06 12 13 OP36 OP37 18 37 14 OP37 12, 13, 16,17, 23 All staff must undertake training in the following mandatory topics: Manual Handling, Fire safety, Food hygiene, First Aid, Health and Safety and Infection Control Implement formal supervision for 30/03/06 all staff Ensure CSCI is notified of any 28/02/06 event, which affects the health safety or well being of service users under regulation 37; this includes any death of a service user residing in the home. Ensure all records are up to date 30/03/06 and kept as required by regulation. Specific records must be kept to evidence water outlet temperatures are regulated to 43 DS0000061213.V271758.R01.S.doc Version 5.0 Page 28 Rosemeadow Residential Home 15 OP38 16 17 OP38 *RQN 18 *RQN degrees and that the emergency lighting is tested at least monthly. Fire drills and names of who participated. 23 Provide evidence of annual Gas safety certificate and a five-year electric circuit safety test certificate and a fire safety risk assessment to CSCI. [Include a risk assessment for the open fire and for staff to ensure the guard is secured at all times] 12,1 3, 16 Ensure cleaning materials are stored appropriately [not stored on top of the medicines trolley] 26 Provide evidence of regulation 26 visits and reports being undertaken and keep a copy for inspection in the home. 17 Provide details of the homes fax number to CSCI 28/02/06 28/02/06 28/02/06 28/02/06 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 OP3 Good Practice Recommendations Add foot care into the assessment document as standard 3.3 and include assessment tools for nutrition, tissue viability, mobility etc and include information about the issue/risk of holding a bedroom door key and key to a lockable facility Further develop the care plans in providing clear instruction/direction to staff in how the service users needs are to be met and include service users choices and preferences. Where service users or their relatives do not wish to be involved with care plans a signed declaration of such should be obtained. Staff should be aware of which type of eye drop needs storing in a fridge and those not required to do so. DS0000061213.V271758.R01.S.doc Version 5.0 Page 29 2 OP7 3 4 OP7 OP9 Rosemeadow Residential Home 5 OP9 Obtain a copy of The Royal Pharmaceutical Societies Guidance for Administration of Medicines in Care Homes Separate out the general information for poisoning and drug error and give staff appropriate guidance for contacting the GP or NHS helpline in the event of this for advice. Ensure a system is in place for stock rotation of dressings and creams Ask service users if they require privacy blinds or nets in their bedrooms and include in the care plan. Consider increasing the hours for activities provision Ensure information is available regarding the homes policy for maintaining service users contact with relatives etc Undertake a service user survey to focus on meal options, supper times and issue raised by service users and review the menu and meal provision in accordance with service users wishes. Provide menus on the tables. Devise a formal template to document complaints and keep with letters in a ring binder file. Further develop the quality monitoring systems and audits in the home. Improve the recording and receipting system for service users small cash held and for any valuables kept on service users behalf Continue to develop policies and procedures as specified by the NMS. Undertake risk assessments for all safe working practice topics. 6 7 8 9 OP9 OP10 OP12 OP13 OP15 11 12 13 14 15 OP16 OP33 OP35 OP37 OP38 Rosemeadow Residential Home DS0000061213.V271758.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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