Inspection on 23/08/06 for Roseville

This inspection was carried out on 23rd August 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Roseville 01/11/07

Roseville 24/02/06

Roseville 30/11/05

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Roseville Marine Gardens Preston Paignton Devon TQ3 2NT Lead Inspector Michelle Finniear Key Unannounced Inspection 23rd August 2006 07:50 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 Roseville DS0000065294.V302485.R02.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. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roseville Address Marine Gardens Preston Paignton Devon TQ3 2NT 01278 741279 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) Underhill Care Ltd Mrs Dianne Bradley Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (22) Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/2/2006 Brief Description of the Service: Roseville is a detached property situated in a level residential area, approximately 200 yards from the sea front and quite near to local shops. The home cares for up to 22 service users aged 65 or over, who may have varying levels of physical and/or mental frailty. The home benefits from having level access to the ground floor, where the communal rooms are situated, and the garden. There is a shaft passenger lift to the first floor. All bedrooms are single rooms, and all have en suite toilet and washbasin facilities. There is a car parking area at the front of the building. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a summary of a cycle of Inspection activity at Roseville since the last inspection visit to the home in February 2006. To help CSCI make decisions about the home the owner and manager gave us information in writing about how the home is run; documents submitted since the last inspection were examined along with the records of what was found at the last inspection; a site visit totalling 6 ½ hours was carried out with no prior notice being given to the home as to the specific date and timing of the first visit; discussions were held with the manager and staff on duty; various records were sampled, such as care plans and risk assessments; questionnaires were sent to staff who work at the home; a tour was made of the home and garden; and time was spent with the people who live at the home both individually and in groups. In addition a sample group of service users were selected and their experience of care was ‘tracked’ and followed through records and discussions with staff and management from the early days of their admission to the current date – looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. Time was then spent with these service users, and questionnaires were sent to their relatives, general practitioners and care managers where appropriate. This approach hopes to gather as much information about what the experience of living at the home is really like, and make sure that service users views of the home forms the basis of this report. What the service does well: Roseville has a comprehensive programme of activity for service users, which has been enhanced by the provision of an accessible vehicle for service user and home use. On the day of the inspection service users had opportunities to participate in an exercise group and quiz in the morning, with a slide show on local history and Agatha Christie in the afternoon. This high level of organised activity is commendable, particularly with the levels of disability at the home. The night before the unannounced inspection the manager had stayed at the home all night to help staff care for a service user who had been very ill, and provide the staff with support and backup. This demonstrated a genuine concern for the staff and service users well-being, and a real commitment to the home. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 6 The home has now enrolled all of their staff on NVQ programmes, and has a new induction programme for staff which is also commendable. An NVQ is a recognised award to demonstrate the level of skill and competency of the staff group. The home has developed comprehensive management systems to ensure service users care is of a high quality. As an example the home has demonstrated excellent outcomes for service users in the areas of health and personal care, daily life and social activities and management. The home is a comfortable living environment. The majority of the rooms have en-suite facilities, many with showers and baths as well as toilets and wash hand basins. Service users confirmed that the home was a good place in which to live, “This home is excellent” being a typical comment. These comments were also backed up by returned comments from relatives and from local medical practitioners. Staff were praised for their kindness. What has improved since the last inspection? What they could do better: The home manager should ensure that where service users have insisted that the window restrictor is not fitted to their window that they are asked to keep their room locked when not in it. This is to prevent a service user coming into their room and falling from an unprotected window. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 7 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. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 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 Roseville DS0000065294.V302485.R02.S.doc Version 5.2 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, 2, 3, 4, 5, 6 Quality in this outcome area is good. Service users and potential service users receive good information about the home before making a decision about whether the home is the right place for them. EVIDENCE: The home has a statement of purpose and a service user guide available, which details information about the home. A copy of this has been given to each service user who lives at the home and can be given to prospective service users before they make a decision about whether they wish to move into the home. This also contains a copy of the homes contract or terms and conditions statement. This document gives information on the home’s fees and what the service user can expect in return. Service users or their relatives who completed questionnaires before the inspection indicated that they had received sufficient information about the home before deciding to move there. One confirmed support had been given to them by social services as well. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 10 On the day of the inspection site visit the files for four service users were seen, which included details of the process that had been followed when they first came into the home, including pre-admission assessments. This was discussed with the manager and in one case with the service user. The files selected included information on a service user who had been recently admitted to the home from another home, which had closed. The manager had visited and met the service user in their previous placement and had discussed their needs with the previous home owner as well, so had a good idea of the level of care that was needed before a decision was made that Roseville was the right place for this person to come and live. Pre-admission assessments like this reduce the risk of service users moving from home to home as they have complex needs that are difficult to meet, and hopefully ensure as well that the service user will be compatible with the other people who already live at the home. For the service user it means they are can feel confident that the home will be able to meet their needs. The homes admissions policy and procedure indicates that service users wherever possible are offered trial visits. Trial visits are important as they enable the service user to decide whether they feel the home is the right place for them, however it is accepted that this is not always possible for every service user. During the site visit a potential new service user visited the home and was supplied with a copy of this information, was given a tour of the accommodation available, and had an opportunity to meet with staff which gave time for the assessment of the persons needs to be carried out. The home does not provide intermediate care. This means they do not provide intensive programs of rehabilitation as a specialist function within the home. The home does however provide respite care if a bed is available and the service users’ needs can be met. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in these outcome areas was excellent. Service users receive excellent health and personal care. Medication systems were satisfactory. EVIDENCE: Care plans for four service users were seen in depth on the site visit. The plans consist of an assessment of the person’s needs, and a plan for how those needs are to be met. This might for example include an assessment of nutritional intake and of any support the service user may need to help them with eating. Wherever possible the plans had been seen by the service user or their representative, which helps the service user to feel in control of the care that is being given and ensure it is being done as they wish. Assessments and plans were then discussed with the manager and staff on duty, and were then directly related to the service user they referred to. Plans were very comprehensive, well maintained, regularly reviewed and person centred wherever possible. This means that they were written specifically for this service user and were not generalised plans. Plans contained detailed information on how the individual liked their care to be delivered and were Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 12 written in a way that focussed on the skills the service user has retained rather than just on the help they needed. This is important in maintaining the selfcare skills of individuals as well as maintaining their self-esteem. A discussion with a staff member identified that they had a clear understanding of the need to ensure service users were encouraged to do as much as possible for themselves, and could explain how they did this for a particular service user. This underlines that staff are working in accordance with the care plan and are clear about the aims and care practice at the home. One service user was very frail, and receiving palliative or end of life care, in conjunction with district nursing and local general practitioner support. The manager of the home had been in attendance at the home all the previous night making sure that this person received the very best of care and that staff felt supported in dealing with them. This demonstrates that the home does provide excellent individualised care and responds sensitively to deteriorations in service user need, for which they are to be commended. Other evidence could be seen in service user files of service users access to healthcare services such as records of hospital appointments. A relative expressed concern over difficulties in accessing dental provision for a service user, which has been a local issue. One service user outlined the number of recent healthcare appointments which they have had to attend at the local hospital and of the staff members who escorted her to ensure she was supported appropriately during the visits. Records had been kept of any accidents and service users most prone to falling had full falls assessments undertaken, and were on the falls monitoring register from the local hospital. Equipment such as pressure relieving mattresses and cushions, specialist beds and hoists were available, some purchased by the home and others supplied on loan from the Health Authority. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. Service users have many opportunities to lead active lives. EVIDENCE: Service user plans contain information on service users life histories and past interests and lifestyle choices. The home has endeavoured to engage relatives and friends in increasing the information available and some have provided good resources, which the home uses to support the service users care. Information on life histories and lifestyle choices is particularly important for service users with some degree of memory loss as service users may no longer be able to remember or communicate this information themselves. Discussions with a senior staff member indicated their understanding of the importance of this information about service users being captured in some way, and the home has started keeping memory books to do this. As a service user recalls an incident or memory of their past the staff record this in a specific book for that service user with their permission. This then can be used later to stimulate the service user in discussion or to recall the incident, with staff having sufficient information to prompt the person where necessary. This is good practice and is to be commended. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 14 Service users have some say in the way their lives operate. As an example at lunchtime a service user had not come down for lunch, so staff were observed telephoning their room to ask them if they wished to come down or have their lunch bought up to them. Some service users were out during the day – one going out for lunch – and others were free to mix with the other service users or remain in their rooms if they wished. One service user said they wished to remain in their room, but understood why staff tried to persuade them to come down to the lounge sometimes as they knew they got very “low” sitting on their own in their room. The home has a full programme of activities for service users to follow. On the day of the unannounced site visit service users were participating in an exercise programme in the lounge in the morning, along with word games and a quiz. In the afternoon there was a slide show about local history and Agatha Christie, which service users really enjoyed. Other activities include art and crafts – copies of service users work could be seen framed throughout the home – musical activities and quizzes. Service users receive home cooked meals that are varied and nutritious. The meal being served on the day of the site visit was soup, beef stew and fresh vegetables with dessert. Breakfast at the home is not eaten in the dining room until 9am, which does mean that some service users have been up for a long time before they have a meal. However they were offered a cup of tea and a paper to read and the manager confirmed that they could have breakfast in their room at any time the service user liked. A cooked breakfast was available. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. Policies for the handling of complaints and management of adult protection issues should protect service users from abuse. EVIDENCE: The home has a complaints procedure, which is detailed in the service user guide which has been given to each service user. The complaints procedure is written in plain English and contains information on people outside of the home to whom complaints may be addressed. This is to ensure that if people were concerned about raising issues directly with the home they would have information provided as to whom they could go to. No complaints have been received by the home or CSCI in the last year, however there was a concern over a staff member on night duty, which was dealt with swiftly and robustly by the home manager. This demonstrates that the home responds to concerns raised to protect service users. Staff have received training in Adult protection, which includes an understanding of abuse and abusive practice. This should help to protect service users from abuse. Staff spoken to showed a clear understanding of the rights of individuals. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. Roseville provides a comfortable environment for service users to live in. EVIDENCE: A tour was made of the home, including service user rooms, the kitchen and the laundry. Roseville is situated close to local shops and the sea front at Paignton. The home has a full passenger lift to access the first floor, and there is some dedicated private parking with on street parking nearby. This means service users who are physically able can maintain contacts with the local community, and can have access to both floors of the home. There is a level garden to the side. Service user rooms very in size and shape, with the majority having en suite facilities consisting of a bath or shower and a toilet, although most service Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 17 users do not use the showers but prefer to use the main adapted baths with a hoist. All rooms are currently for single occupancy. All areas of the home seen on this inspection were clean, warm and comfortable, with service user rooms personalised with items of their own furniture and pictures. Considering several service users have problems with continence management the home was odour free, even at the busiest time of the morning. The front door of the home is kept locked, and there is a code number to exit. One service user has their own exit door from their bedroom, which means that they are not disadvantaged by the door being kept closed. All service user rooms are fitted with call bells, and the manager confirmed that all windows above the ground floor have restricted window opening except for two rooms where the service users have refused to have the restrictors fitted. The service users in these rooms have signed disclaimers but being able to access the rooms could potentially leave other service users at risk. With that in mind the manager agreed to ask the service users concerned if they would ensure their rooms are locked when they are not in them, so that other service users could not gain access to these areas. The home has a communal bathroom on the first floor. A communal toilet is situated near to both the ground floor lounge and the dining room, which means service users do not have to move far from these areas to find facilities. There is a lounge, with television, on the ground floor of the home for service user use, and a small lounge area on the first floor which may be used if service users wish to see visitors in private outside their rooms. Service users bedroom doors have been fitted with locks, which can be secured from inside the room but are openable from the outside in case of an emergency. Since the last inspection the home has provided a new conservatory, which has increased the lounge space available and provides a separate area for service users to use if the main lounge is being used for activities. The homes laundry is to the rear of the home and has been fitted with a new washing machine and tumble dryer since the last inspection. The washing machine is capable of achieving a sluicing cycle for foul linen. This means service users can be protected from any risk of cross infection and their clothes kept clean. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. Service users are protected by the homes policies on staff recruitment, training and employment. EVIDENCE: Copies of the homes staffing rotas were supplied prior to the inspection. The site visit for this inspection took place at 7.50 a.m. to gain a view on how staff were working at the busiest time of the day. An appropriate number of staff were on duty to care for the service users and although the home was busy, service users were receiving appropriate attention. Some service users were waiting a long time for their breakfast, but the manager confirmed this could have been given to them in their rooms earlier if they had wished. The morning start time for day duties has been moved forward to 7:30 am to allow for more staff to be on duty at this busy time of the day as previously there would only have been night staff on until 8am. The home manager has the authority to bring additional staff on duty if she feels the home is short staffed. She had herself remained at the home overnight to support the night staff with a service user who was very frail. Four staff files were selected at random for inspection. Staff files contain such recruitment information as application forms, copies of references, and criminal records bureau checks. In the four files examined this information was all present, with the exception of one when a criminal records check was still awaited having been applied for some weeks previously. In this instance the file also contained information as an interim measure a check of the vulnerable Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 19 adults register, which would identify whether the member of staff, who had been recently employed, had previously been found to be unsuitable to work with vulnerable people. This check was satisfactory. The home has an equality and diversity monitoring form for use during staff appointments. Appropriate risk assessments had been carried out where appropriate regarding staff employment matters for example a pregnancy risk assessment. The home uses a key worker system, which means that individual service users have a specific member of staff who has responsibility for that service user, making sure that records are maintained up to date and that they have everything they need. Photographs of key workers are on the back of each service user bedroom door, to remind the service user who their key worker is. Photographs of staff are also on a board near the door, with their names, and staff are now wearing badges which helps service users with recalling names. Discussion was held with the manager on staff training that has been provided since the last inspection. The manager has implemented an excellent induction package she has developed herself, based on the skills for care Value based standards. Information from this induction course is mapped across the NVQ standards. This means that staff are receiving comprehensive induction training to care at Roseville, the standards of care required, an understanding of why care needs to be delivered in a particular way and of the values of the home. These should mean staff are better able to support service users in a consistent way, based on best practice and an understanding of the holistic needs of service users. This is commendable. Significant other training is also occurring at the home with five staff currently undertaking National vocational qualifications and several others due to start in the near future. The home has an NVQ assessor as a senior carer. Other training that has been held at the home since the last inspection has included moving and handling, first aid, fire prevention and food hygiene and handling. National vocational qualifications are an award assessing the competency of staff in their day-to-day work. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is excellent. Roseville is being well run. EVIDENCE: The manager of the home Mrs Dianne Bradley was registered last year. She is a very experienced nurse and nurse manager, and was previously employed as the homes deputy manager. In the time that she has been registered she has implemented some excellent new practice and systems, in conjunction with the new owners of the home who were registered towards the end of 2005. These improvements have enhanced both the running of the home and also the individual lives of service users. One of the new developments has been the implementation of a full quality assurance system. This system incorporates a series of questionnaires for service users, relatives and other stakeholders. Questions are focused in three Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 21 areas namely about the home, about living in the home and care in the home. Some of these questionnaires are designed to be completed with the service user and their family, or by the service users with the other support if required. There is also a staff questionnaire. Following the return of these questioners a statistical rating Value is given to the answers which can demonstrate areas where the home is achieving excellence, and areas where additional improvement could be sought. A copy of the summary of results from these questionnaires is given to service users and potential service users in the service user guide, and a copy has been supplied to the commission for social care inspection. The home also has a series of internal audits, and a representative from the company visits on a monthly basis and carries out an external audit. Results from all of these and other activities within the home such as staff meetings are collated and feed into the annual development plan for the home. These should allow the home to get a good idea about service users views on the services provided and develop any areas identified as needing improvement. Resident’s monies are paid into “Roseville Residents Bank Account”. The manager and a senior carer are the named holders of the account. The manager explained the procedure for withdrawal of monies, which are taken out of the account and held in named envelopes for resident’s ease of access. Financial records and receipts for transactions were seen, and two sample accounts were checked with the amount of cash held. One balanced perfectly, in the other there was a slight discrepancy in the service users favour. Records for personal expenditure on behalf of service users was signed and receipted where appropriate. A small number of residents manage their own finances with support from families. The home has also implemented a full and comprehensive system of supervision for staff which is dealt with by a senior staff member with annual appraisals completed by the manager. Supervision is a system which combines elements of performance management and staff development, and ensures that staff are working to their full potential and working consistently to support service users. The system in use comprises interviews, observation of practice and developmental issues such as training being undertaken. Staff spoken to confirmed they receive regular supervision and this was then verified through an examination of records and discussion with the senior person responsible for the delivery of the system. A full external health and safety audit has been carried out by a specialist company, which identified areas for the home to develop, which have now been completed. Health and safety training is offered to new staff at induction. The home has health and safety files and risk assessments have been carried out for all working tasks and for the homes environment. The home keeps records of all accidents and monitors falls closely. Chemicals and cleaning products were being stored safely on the site visit and proper arrangements Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 22 were in place for maintaining control of infection and providing a clean environment for service users. Staff have received training in moving and handling, first aid and food hygiene. Fire prevention training is in place and the homes fire log book evidenced that regular tests of the fire equipment were being undertaken. The home has hoists, bath hoists and a stand aid as well as some electrically operated beds. These aids ensure that as far as possible staff are not having to move or lift service users manually, risking damage to their backs or the service user. Electrical tests are regularly completed on appliances and the home has been tested for legionella, and the manager believes asbestos. Water temperatures are regulated, so service users are protected from any risk of accidental scalding. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 23 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 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 4 X 3 Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations The home manager should ensure that where service users have insisted that the window restrictor is not fitted to their window that they are asked to keep their room locked when not in it. Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Roseville DS0000065294.V302485.R02.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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