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Inspection on 26/04/06 for Rosemeadow Residential Home

Also see our care home review for Rosemeadow Residential Home for more information

This inspection was carried out on 26th April 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Provides a homely environment in which residents are treated with respect. Their daily lives suit their individual preferences and abilities. Staff including the registered provider, are thought of as friends by the residents, and are approachable.

What has improved since the last inspection?

3 large single rooms are now fitted with an ensuite facility. Recruitment practice has improved and ensures that staff are suitable to work with vulnerable adults. 1 new hoist has been purchased. Improved record keeping provides better reference to enable appropriate monitoring of training. The home now reports under regulation 37 any event in the home that affects the wellbeing of the residents. Three meal options are now available at lunchtime.

What the care home could do better:

The registered person must ensure that the home`s statement of purpose correctly addresses all of the requirements as listed within the National Minimum Standards to provide prospective residents information on which to base their decision to come into the home. The manager must ensure that systems are in place to appropriately record all the requirements for staff recruitment, induction, foundation and mandatory training, and evidence of supervision. The staff training can then be organised to ensure that all staff have the appropriate training each year and that the training is appropriate to the job they are to perform. Where staff receive training to undertake blood tests in the home, there must be a policy in place that reflects the home`s responsibilities under the health and Safety at Work Act, ensuring that staff have received appropriate Hepatitis vaccination to protect them. Whilst it is acknowledged that residents at the home are referred to external specialists if they are considered at risk of pressure sores, the manager must obtain an appropriately recognised risk assessment tool for tissue viability and nutrition, which will ensure that residents receive preventative rather than restorative treatment. The home has purchased a number of policy statements, whilst these may provide a starting point for the manager they must be reviewed to ensure that each one is pertinent to the home`s individual practices and recognised local policy such as Adult Abuse. The manager must ensure that she is informed about the numbers of staff required to enable her to allocate the appropriate number of staff on duty.Some areas of Health and Safety could not be verified. The home must produce a policy on its arrangements for Heath and Safety, setting out the responsibilities and arrangements in place. Environmental risk assessments should highlight the few issues that may present a risk to the residents. The manager must ensure that residents are safe from radiators, hot water and windows by fitting appropriate devices to protect people. The new ensuite rooms must be fitted with emergency call bells for residents to use. Any resident that is unable to manage their own finances must receive a review by their social worker and appropriate financial protection sought. The office space is cramped and untidy, there is limited storage. The office should provide adequate storage and organised space in which to work.

CARE HOMES FOR OLDER PEOPLE Rosemeadow Residential Home 119 Station Road Misterton Doncaster South Yorkshire DN10 4DG Lead Inspector Mary O`Loughlin Unannounced Inspection 26th April 2006 10:00 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.V291845.R01.S.doc Version 5.1 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.V291845.R01.S.doc Version 5.1 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 Joyce Rose MacLennan Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 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 handrails fitted to assist with mobility problems. The range of fees is from £297.00 to £335.00 Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over 6 hours and was unannounced. The registered provider and the Registered manager were present and provided information to inform the report. Evidence for the report was obtained by examining the admission process, the care planning and the care delivery of the residents. Three residents records were examined, two staff files and the specific policies relating to the standards inspected. One relative and 4 residents provided their views on the service. The inspection found that within this small friendly home, residents and relatives were very happy with the care they were receiving and their daily lives. What the service does well: What has improved since the last inspection? 3 large single rooms are now fitted with an ensuite facility. Recruitment practice has improved and ensures that staff are suitable to work with vulnerable adults. 1 new hoist has been purchased. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 6 Improved record keeping provides better reference to enable appropriate monitoring of training. The home now reports under regulation 37 any event in the home that affects the wellbeing of the residents. Three meal options are now available at lunchtime. What they could do better: The registered person must ensure that the home’s statement of purpose correctly addresses all of the requirements as listed within the National Minimum Standards to provide prospective residents information on which to base their decision to come into the home. The manager must ensure that systems are in place to appropriately record all the requirements for staff recruitment, induction, foundation and mandatory training, and evidence of supervision. The staff training can then be organised to ensure that all staff have the appropriate training each year and that the training is appropriate to the job they are to perform. Where staff receive training to undertake blood tests in the home, there must be a policy in place that reflects the home’s responsibilities under the health and Safety at Work Act, ensuring that staff have received appropriate Hepatitis vaccination to protect them. Whilst it is acknowledged that residents at the home are referred to external specialists if they are considered at risk of pressure sores, the manager must obtain an appropriately recognised risk assessment tool for tissue viability and nutrition, which will ensure that residents receive preventative rather than restorative treatment. The home has purchased a number of policy statements, whilst these may provide a starting point for the manager they must be reviewed to ensure that each one is pertinent to the home’s individual practices and recognised local policy such as Adult Abuse. The manager must ensure that she is informed about the numbers of staff required to enable her to allocate the appropriate number of staff on duty. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 7 Some areas of Health and Safety could not be verified. The home must produce a policy on its arrangements for Heath and Safety, setting out the responsibilities and arrangements in place. Environmental risk assessments should highlight the few issues that may present a risk to the residents. The manager must ensure that residents are safe from radiators, hot water and windows by fitting appropriate devices to protect people. The new ensuite rooms must be fitted with emergency call bells for residents to use. Any resident that is unable to manage their own finances must receive a review by their social worker and appropriate financial protection sought. The office space is cramped and untidy, there is limited storage. The office should provide adequate storage and organised space in which to work. 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.V291845.R01.S.doc Version 5.1 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.V291845.R01.S.doc Version 5.1 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): 1-3-6 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have the full information to make an informed choice about where they live. Residents are assessed prior to coming into the home to ensure their needs can be planned and met. Intermediate care is not provided. EVIDENCE: The previous inspection required the manager to review the Statement of purpose and include all of the required information to meet the minimum standard. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 10 The statement of purpose was examined during this visit and although reviewed there was still some information that was not included, which is required to meet the National Minimum Standard. The records of admission assessment for residents remain the same as no new residents have been admitted since the last inspection. Intermediate care is not provided. There are no residents receiving day care at this time. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-8-9-10 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Residents are treated respectfully at the home and their right to privacy is upheld. The health, personal and social care needs are properly recorded and ensure that residents receive care according to their wishes. Medicines are generally well managed and ensure the safety of the residents. EVIDENCE: Three care plans demonstrated that the manager has implemented a more comprehensive recording system. Each plan was organised and gave a clear history of the resident’s condition. The plans are signed by the resident if they wish and they are consulted on this as records demonstrated. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 12 The minimum standard requires that residents are assessed for their risk of developing pressure sores, good practice would be to have a risk assessment tool that is completed monthly and as the resident’s condition changes, this would then inform a plan of care that ensured appropriate intervention took place to reduce the risk of any pressure sore developing. The home does not have a pressure sore risk calculator and there was no record of staff receiving training in pressure sore prevention. This may not protect the resident from the development of a pressure sore. The manager was advised to obtain information from the District Nurse attending the home but the district nurse would not provide the manager with the local risk assessment tool for pressure sore risk. Risk assessment tools are available and should be researched and implemented at the home. There was no nutritional tool available to assess any nutritional risk. Residents are weighed monthly and any problems are referred to the Doctor. Care plans did record the nutritional requirements. There was good information on how the resident’s personal hygiene was met, how staff attend to their needs and it included the personal preferences of the resident. The residents plans demonstrated that each person is registered with a GP of their choice, they have access to NHS facilities such as chiropody, dentistry and ophthalmology. Each resident has a mobility assessment and ensures appropriate opportunities for the person to exercise within their abilities. Mobility aids were in use. Two staff members have received training in testing the resident’s blood for glucose levels. There is no protocol in place that reflects best practice when staff are undertaking this procedure, which would ensure that there were clear lines of accountability and clear guidance on the procedure. One staff member whilst being trained to undertake blood testing said she was not confident in the practice. Plans are reviewed at least monthly. Medicines are held securely as required. Storage temperatures are now recorded as required. Residents have a medicine record sheet with their photograph attached, which is good practice. Staff are trained to administer the medicines safely. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 13 Medicines are recorded into and out of the home and this provides an audit trail to ensure no misuse. Controlled medicines are held within a lockable box within the medicine trolley and records are held. One medicine record had been altered without a signature, which is poor practice. The manager said she had obtained a copy of the Royal pharmaceutical society guidance for the administration of medicines in care homes, but could not find it. The reviewed policy for drug administration error reporting was seen and provides guidance to staff in the event of an error occurring. Throughout the inspection staff were seen to treat residents respectfully. All residents spoken with felt they had a good relationship with the staff and were treated well. Residents have access to a telephone for private use and receive their mail unopened. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 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 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents at the home have a lifestyle that matches their expectations and preferences, and satisfies their social, cultural and religious needs. Residents are supported to maintain contact with their family and friends, exercising choice and control over their lives. The choice of diet ensures that residents receive nutritious and wholesome food according to their preferences. EVIDENCE: The last inspection found that suitable arrangements were in place for the daily life and social activities of the residents. This inspection focused on the views of the residents at this time. One relative and three residents were spoken with, all were happy with the lifestyle and opportunities available to them at the home. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 15 The relative spoke of being invited to social events such as a bonfire night party and Christmas party, both of which had been enjoyable and food provided was excellent. The residents felt that the lifestyle suited them, they did not wish to have a too active a lifestyle and felt that they were able to be independent and socialise as they wanted. They were able to go to bed and get up as they pleased. There was no restriction on visiting. The local minister provided a service at the home monthly. Residents had developed friendships with each other and were chatting and laughing with each other during the day. The meal of the day was displayed on a menu for all to see, there were three choices of main meal, which is excellent. Every resident commented on how good the food was, as did the relative. The Environmental Health Office has conducted an inspection recently and provided the manager with the required legislation update for “Safer Food” risk assessment. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 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 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity through good relationships with the provider and the staff to make constructive suggestions. The open culture allows residents to feel confident that they are listened to and any problems are immediately acted upon. 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: There have been no recorded complaints or Adult Protection referrals since the last inspection. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 17 The manager has a book in which she will record complaints if she receives any. The home has a complaints policy in place that is made available to all residents and relatives. Residents said they only had to ask if they wanted something, they know who the manager is and would speak with her if they had any concerns. The relative felt that the Provider was respectful and approachable to discuss any matters of concern. There is a copy of the Nottingham Vulnerable Adults procedure at the home, which the manager confirmed she would follow in the event of any suspicion or allegation of abuse. The home has also got a separate policy statement which does not reflect the fact that the Nottingham policy is to be followed which may confuse staff and not ensure that the actions taken will be appropriate. Some staff have undertaken training in Adult Protection but it is not clear how many as records are in the process of re-organisation. The home’s practice regarding resident’s money and financial affairs provides appropriate recording and safekeeping. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 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 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. A comfortable, clean and generally safe standard of accommodation is provided for residents. Refurbishment and repairs are ongoing. Essential equipment for the residents is in place to meet their needs. There are appropriate safeguards I place to protect residents from cross infection. EVIDENCE: Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 19 The home was clean and warm. There was no malodour. The previous inspection found the home was meeting the key standards for the environment. The registered provider has submitted plans to extend and refurbish the original accommodation and is waiting for building control acceptance. 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 been completed. The provider has continued to upgrade the internal building, three rooms have now been fitted with an ensuite, and the size of these rooms still meets the minimum standard. Two of the rooms had not had an emergency call bell fitted within the ensuite, which is required. Where improvements have taken place the provider has fitted low surface temperature radiators and window restrictors. There are some rooms that still have radiators that may present a risk to residents as they are not covered and are not low surface temperature. Not all windows are fitted with restricted openings. The bedrooms are fully carpeted and provide fire retardant curtains. Rooms are lockable, have suitable furnishings and are homely and personalised. Each room has a lockable space in which to store valuables. The laundry room is within the basement area and provides appropriate washing temperatures to control infection. Some areas of the laundry room walls are bare plaster, which does not meet the standard for non-permeable membrane, which allows for proper cleaning. The home has a fire detection system fitted and a fire procedure is in place. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 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 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff may not be calculated to ensure that at all times sufficient staff are on duty. Residents are cared for by staff that are trained in the care of older people, to recognised NVQ standards. The recruitment practice safeguards vulnerable adults. The staff team receive regular updates in their training to ensure best practice for residents care delivery. EVIDENCE: The last inspection required the manager to review the staff hours and ensure that the home provided 210-care hrs; 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. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 21 Care staff are also expected to undertake some domestic and laundry duties and this means that staff are taken from care duties. 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. A record of staff hours and duties was seen; the manager was asked how many staff hours were being provided but was unable to verify this. Residents previously felt that staffing levels could be improved, at this inspection no residents commented on the staffing numbers. Clearly the starting point for the manager is to have knowledge of the required number of staff hours for care and domestic duties. The number and needs of the resident must also inform the staffing levels. Two staff confirmed that they had done Fire training and manual handling training. Over 50 of the staff are trained to level2 NVQ. The previous inspection found; 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 inspection examined 2 staff files and found that recruitment practice is now compliant with the Minimum Standard. The manager has commenced work on the recording of staff training and supervision, however the training record should be more organised to ensure that all staff have the appropriate updates when required. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 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): 31-33-35-38 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. There is a registered manager in place who provides the necessary skill and continuity for the home. Residents views are used to inform the quality of the care provided. Residents are safeguarded from financial abuse. The record keeping and organisational arrangements are confused and do not ensure that all matters of health and safety within the premises are effectively dealt with. EVIDENCE: Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 23 The manager is registered with the Commission. She has recently completed her NVQ 4 in management and is awaiting the certificate. The finances of residents were appropriately managed. Each resident that requires safekeeping of a cash float has a record of the transactions in place with appropriate receipts. The manager is appointee for one resident for DWP purposes. The records are held of all transactions for this person; however, the money is accruing within the home’s safe, which is not acceptable. The manager was advised to request a review for this resident from the social worker involved to ensure that all parties agree the financial management, with appropriate records held of this agreement. A separate bank account must be opened to ensure that the resident receives interest on the savings. Where a person lacks capacity to manage their own affairs, an assessment of their ability must have been undertaken and wherever required access to legal or financial guidance must be sought. Residents are consulted on their care through the care planning process. Satisfaction questionnaires are also completed as part of a quality assurance system at the home. These must inform the service and feedback must be provided to those participating. The manager is proceeding with the implementation of staff supervision. Some records were available to assess the actions the home was taking to manage health and safety issues, however, there was no health and safety policy in place and the records were disorganised. Issues such as Fire testing and emergency lighting tests were compliant. The manager and provider must prepare a health and safety policy statement that explains how the home are meeting its obligations under the legislation Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 24 for all of the legislation within Standard 38.4 of the National Minimum Standards. The office room was somewhat disorganised and files were in poor order. The working space and storage could not adequately cope with the records that required keeping. Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 26 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 The registered person must; ensure the Statement of Purpose and Service User Guides are amended and issued as required by regulation. The registered person must; 1. Ensure that recognised risk assessment tools are obtained to assess the Pressure Sore risk and Nutritional risk of residents. 2. Provide a policy and procedure on the management of the arrangements in place for staff to receive training to test blood glucose levels and the health and safety issues that are considered including control of hepatitis B. 3. Ensure that the medicine policies are accessible at all times. 4. Ensure that hand written medicines are signed and witnessed. DS0000061213.V291845.R01.S.doc Timescale for action 30/06/06 2 OP8 13 30/06/06 Rosemeadow Residential Home Version 5.1 Page 27 3 OP18 13 4 OP27 12, 13,18 5 OP38 13 6. OP38 12, 13, 16,17, 23 The registered person must ensure; 1. The homes own Adult Protection policy refers to the Nottingham Adult Protection Policy as the required action to follow. 2. Ensure that training records reflect that staff have attended training in Adult Protection issues as referred to within standard 18. The registered person must ensure that staffing hours are calculated according to the previously set hours (210) and is regularly reviewed according to the needs of the residents accommodated. The registered person must provide to the Commission a Health and safety policy statement that sets out the arrangements for the home to meet its obligations under the legislation that is within Standard 38.4 of the National Minimum Standards. The registered person must; ensure all records are up to date and kept as required by regulation. Specific records must be kept to evidence water outlet temperatures are regulated to 43 degrees and that the emergency lighting is tested at least monthly. 30/06/06 30/06/06 30/06/06 30/06/06 Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP19 OP26 OP19 OP19 OP29 OP29 OP35 Good Practice Recommendations Ensure that all radiators that are not protected or low surface temperature are risk assessed to ensure that residents are safe. Ensure that the laundry room walls are covered with a non-permeable membrane that allows for cleaning. Ensure that call bells are fitted to the ensuite rooms. Fit window restrictors to all windows that present a risk to the residents. Ensure that all new staff complete a record of induction, which is held within their training records. Ensure that the staff training records are complete and provide a good reference to the training they have undertaken and the training updates that they require. Ensure that where a resident is unable to manage his or her own finances, a review takes place with the social worker and that the manager is appointee only as a last resort. Residents should have their own bank account or an account in their name that is interest bearing. Provide suitable office space and storage. 8 OP38 Rosemeadow Residential Home DS0000061213.V291845.R01.S.doc Version 5.1 Page 29 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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