Inspection on 19/07/06 for Rosewood Care Home

This inspection was carried out on 19th July 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

Rosewood Care Home 31/07/07

Rosewood Care Home 11/10/05

Rosewood Care Home 19/04/05

Rosewood Care Home 07/12/04

Rosewood Care Home 14/09/04

Rosewood Care Home 30/01/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Rosewood Care Home 131a Swift Road Woolston Southampton Hampshire SO19 9ES Lead Inspector Neil Kingman Unannounced Inspection 19 July 2006 09:50 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 Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosewood Care Home Address 131a Swift Road Woolston Southampton Hampshire SO19 9ES 023 8068 5224 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) Mycare Homes Limited Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11 October 2005 Brief Description of the Service: Rosewood is a registered residential care home providing care and accommodation for up to twelve older people who need some assistance with personal care needs. The home is situated in Swift Road Woolston about a ¾ mile from the local shops and about the same distance from Weston Shore. Single room accommodation for residents is provided on the ground floor, with a staff sleeping-in room on the first floor. WC facilities are mostly shared between rooms. An enclosed garden and patio area is to the rear of the home with seating for residents’ use. There is a small off-road car park to the front, from which there is level access into the home via the front door. At the time of this key inspection the home was undergoing a major development, which included a large extension and garden landscaping. The inspector took this into account when assessing the standard of the environment, especially the front and the garden at the rear where the impact of the building work was felt most by residents and visitors. Weekly fees are £413.00. The acting manager states that a copy of the home’s service user’s guide is provided to all residents, a copy of which is located in each room. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Rosewood and brings together accumulated evidence of activity in the home since the last key inspection on 11 October 2005. The acting manager forwarded to the Commission a selection of pre-inspection information about the service. Part of this inspection was to undertake a site visit to test the information provided. The inspector looked at records, spoke with the acting manager, the proprietor, care staff and residents, and toured the building. Included in this inspection have been telephone discussions with a social services care manager and a district nurse who visit the home, and also three visiting relatives. There was only one response to the care home’s survey received from a service user who, at the time of the site visit was no longer resident in the home. The views about the service were mixed, but generally positive. They reflected the fact that improvements had been made since the last inspection. What the service does well: What has improved since the last inspection? Progress made by the home since the last key inspection on 11 October 2005 include: • • • The interim appointment of an acting manager. Staff training needs identified and courses scheduled. Work undertaken to bring fire resistant doors up to standard and new signage put in place. DS0000011616.V294294.R01.S.doc Version 5.2 Page 6 Rosewood Care Home • • • • • Increased security arrangements with alarms fitted to fire doors. All requirements relating to food preparation, cooking and quality addressed. The home’s complaints procedure made more accessible to residents and visitors. Serious shortfalls in the home’s staff recruitment procedure addressed. A review undertaken of the activities offered to residents. What they could do better: The overriding concern identified at this, and previous inspections is the lack of a registered manager. This issue must be addressed. While there were very positive outcomes from the inspection there were four requirements identified as needing attention: • • • • The need to tighten up procedures relating to residents’ medication. To provide liquid soap and disposable towels in all areas of communal hand washing. To provide staff references where gaps are identified. To ensure that fire doors are only held open by approved means. In terms of good practice the inspector recommended the following: • • While staff training is ongoing and up to date the induction programme for new staff has changed and the new Common Induction Standards need to be introduced. References to the regulatory body in the home’s adult protection policy need to be updated. At the time of producing this report the home has confirmed in writing the action taken to address all the requirements except the issue of a registered manager. 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. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager ensures that the care needs of the people who live at Rosewood will be met by undertaking a proper assessment prior them moving into the home. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. EVIDENCE: It has been shown at previous inspections that pre-admission assessments are carried out on new residents before they move into the home, to provide the best possible assurance that the home will be able to meet their needs. At this site visit it was noted that the practice continues. The inspector looked at care records for the newest resident admitted the previous week from a residential home in the north of the country. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 9 Due to the distance involved with this particular placement it was not practicable for the usual pre-admission assessment to be carried out. However, the acting manager demonstrated that she had done all that was reasonably possible to obtain detailed information about the new resident. This included full needs and risk assessments from the placing authority, and an assessment provided by the residential home from where the new resident had come. All this information was noted to be on the resident’s care file. Residents at Rosewood are long term. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of care planning with an individual plan for each resident. They provide a good demonstration that residents’ health and social care needs are identified and met and include risk assessments and monthly reviews. The home promotes and maintains residents’ healthcare and ensures that access to healthcare services is available at all times. Medication is held in secure, but not ideal conditions. While appropriate records are generally maintained there are areas that could be improved. The home ensures that staff respect residents’ privacy and dignity at all times, especially with regard to the arrangements for health and personal care. EVIDENCE: The principal of case tracking was used in a sample of three care plans. The intention was to look at the outcomes for residents in general by assessing all Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 11 areas of care for those sampled. The sample included the newest admission to the home, a resident from an ethnic minority background and a very assertive and articulate person with mobility difficulties. Each resident has an individual personal care plan. Those seen contained an assessment of social, physical and medical needs together with a plan of care which gave a good demonstration of how the needs were to be met. They contained information to show that specialist healthcare professionals were accessed as and when required. Risk assessments were in place and each had a record of significant events. Staff spoken with described how they operated a key worker system where they undertook monthly reviews on those residents they were responsible for. Residents spoken with showed little interest in their own care plans. However, one relative visiting a mentally frail resident was fully aware of the individual’s care plan and was actively involved in its compilation, and discussions with the acting manager about the information it contained. The acting manager said that while there was no incidence of pressure sores there was a need to practice good continence and pressure area management as at least one resident was at risk. Staff confirmed that pressure areas are managed with appropriate equipment and visits from the district nurse. This fact was confirmed in discussions with one of the nurses. Most residents are local to the home and retain their own GP. Those admitted from outside the catchment area are registered with the local practice where there are four GPs. The acting manager said that while there is no difficulty in obtaining the services of an optician and chiropodist the dentist can be problematic. Although a Southampton dentist has in the recent past paid a domiciliary visit, they normally have to resort to the ‘flying’ dentist facility for emergencies. Two residents were full of praise for the efforts made by the home to meet their medical needs and one gave several examples. Medication is dispensed by means of a monitored dosage system by staff who have completed medication training. At the time of the site visit medication for residents was securely held. However, the storage facilities are not purpose built. They were noted to be cramped and in different areas, one being in the dining room. It was understood from the acting manager that medication storage would be addressed with facilities in the new build. The inspector noted that correction fluid had been used to amend one entry on a Medication Administration Record. Otherwise, records relating to the safekeeping and administration of medicines in general were in order. The use of correction fluid had also been noted on a resident’s care record. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 12 It was noted that PRN medication lacked individual protocols, informing staff about when to administer the medicine, expected reaction times and any contra indications. The acting manager said she would seek guidance from the pharmacist. During the course of the site visit the inspector saw staff knocking before entering residents’ rooms, and addressing them by their preferred name. In interviews with staff they showed an understanding of the importance of treating residents with dignity and respect. The visiting relative spoken with, and residents who could give an opinion, were full of praise for the staff and the way they were treated. The home provides a portable phone, which can be used by residents in any part of the home. Some residents have their own installation in their room. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines in the home are flexible and informal. The provision of activities to suit residents’ needs and preferences has improved since the last key inspection. Friends and family are welcome to visit at any time, but are requested to avoid mealtimes where possible. Families support residents unable to manage their own financial affairs. The facilities of the advocacy service are arranged for those who wish to use them. The promotion of choice extends to all aspects of daily living including personalisation of rooms, and meals. The nutritional needs of residents are satisfied with a varied and balanced diet of good quality food. Shortfalls identified at the last key inspection have been addressed. EVIDENCE: An activities programme for residents can be found on the door to the lounge and includes various games, arts and crafts, reminiscence, quizzes, structured Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 14 exercises, raffles and visiting entertainment. During the afternoon of the site visit there was entertainment from a visiting singer. Not all residents attended, but those that did appeared to enjoy singing along to some popular music. It was clear from discussions with residents that some preferred their own company in the privacy of their rooms. An issue at the last inspection was that residents are not offered opportunities for trips out. The acting manager said that the cost of trips to places of interest and entertainment had been explored, and given that so few residents expressed an interest it would not have been viable. However, the expectation was that when the new development was completed there would be additional opportunities for residents. Visiting arrangements can be found in the statement of purpose, a copy of which is available in the hall. Visitors are welcome at any time but are requested to avoid mealtimes where possible. Residents can receive visitors in their own rooms or any of the communal areas, including the patio outside on warm days. The acting manager said that all but one resident have their family to represent them, and that the facility of the advocacy service had been offered and refused by one who had no family support. This was confirmed in discussions with the resident who clearly had made other arrangements. Residents are encouraged to personalise their rooms and during the tour of the building the inspector noted varying amounts of personalisation, from very little to a great deal of personalisation in rooms according to individual needs and preferences. At the last key inspection requirements were made to train staff in food hygiene and to provide adequate food supplies. There was evidence at this inspection that the issues had been addressed. The inspector noted the training had been completed and the acting manager confirmed that she had responsibility for the food budget, enabling her to ensure that food purchases met with resident satisfaction. Those spoken with were generally satisfied with the quality and variety of meals and one relative made special mention of the fact that the resident very much enjoyed the food. Currently the responsibility for food preparation and cooking falls with the care staff. However, it is understood that the appointment of a dedicated cook will be considered when the new build has been completed. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ complaints are treated seriously and given an appropriate response. The home’s policies, procedures and practices ensure that residents are safeguarded from abuse. However, references to the regulatory body in policies need to reflect the change from the National Care Standards Commission (NCSC) to the Commission for Social Care Inspection. EVIDENCE: The home has a policy and procedure for dealing with complaints, which is set out in the statement of purpose, and also in the service user’s guide. The acting manager said that since the last inspection the complaints procedure has been regularly reinforced at residents’ meetings and details of the procedure prominently displayed in each resident’s room. The inspector looked at the complaints register and noted the last recorded complaint from a resident was in March 2006. It gave details of the complaint and what was done about it. While residents and relatives spoken with were not aware of the precise detail of the home’s complaints procedure they all said they would address any concerns to the acting manager whom they had confidence in. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 16 The home has an adult protection policy and procedure in place, which links with local authority guidance. However references to the regulatory body need to be updated. The manager confirmed that adult protection training for staff is scheduled and some had already been completed. One member of staff spoken with had just completed the adult protection training and another was scheduled to undertake it in the future. Both were very clear about the importance of reporting issues of concern without delay. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 – Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Rosewood is generally accessible, safe and well maintained. However, it is currently undergoing a major development. The home endeavours to keep to a minimum the inconveniences that building work entails. On the day of the site visit the home was clean, hygienic and there were no unpleasant odours. However, liquid soap and disposable towels are required in all areas of communal hand washing. EVIDENCE: Rosewood is a care home providing ground floor accommodation accessible to all residents. Due to the extensive building work access to the rear garden is restricted, as is parking to the front, which is predominantly occupied by site vehicles while work is in progress. Inside the effect of the building work is currently minimal. The inspector toured the building with the manager and noted rooms to be reasonably decorated and well personalised. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 18 All residents are accommodated in single rooms, most with interconnecting ensuite toilet facilities. In discussions with a visiting relative the lack of a shower with disabled access was highlighted. The acting manager was aware of the situation and confirmed that such a facility would be included in the new build. While the home was generally found to be clean and free from unpleasant odours the feedback from visiting relatives highlighted an occasional lack of attention to cleaning. During the tour the inspector noted a lack of liquid soap and disposable towels in WCs and bathrooms. This has the potential for cross infection. At the time of producing this report the home has confirmed in writing that this requirement has been met. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 19 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 and 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and mix of skills are adequate to meet residents’ needs. To ensure residents are in safe hands arrangements are made for staff to undertake NVQ training. At the time of the inspection 80 of care staff had achieved the NVQ at level 2/3 or equivalent. In general terms the home operates a robust recruitment procedure, which ensures residents are protected. However, it is important to ensure that a minimum of two written references are in place for all staff. The staff training and development programme ensures the residents’ needs are met in line with the aims of the home. EVIDENCE: The home employs eight care staff, one domestic and an acting manager. On the day of the site visit there were nine service users resident in the home. Staff rosters showed and the acting manager confirmed that a minimum of two care staff is deployed between 08:00 and 22:00. The acting manager works both on shift and in a supernumerary capacity. On the day of the site visit there were two care staff and the acting manager on duty. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 20 Overnight there is one wakeful and one sleep-in carer in the home. These staffing levels are considered adequate for the current needs and numbers of residents in the home. The acting manager said the issue of long working hours had been addressed with care staff working no more than 65 hours in a working week, after having signed an ‘opt-out’ clause to the recommendations of the Working Time Directive. Residents, visiting relatives and professionals who were consulted during the inspection process raised no concerns about staffing levels, generally feeling they were adequate for current needs. Residents spoken with in the privacy of their rooms said the care was very good and that they felt safe in the home. Currently 80 of care staff have achieved the NVQ at level 2/3 or equivalent and two further care assistants are scheduled to start the training in September 2006. The inspector noted a significant improvement in the home’s recruitment procedure as there were serious shortfalls identified at the last inspection. Individual staff files were available for inspection and included an application form, interview questionnaire, employment contract and police and Protection of Vulnerable Adults (POVA) checks on all staff. During the inspection the recruitment records of all staff were checked and found generally to be in order. However, it was noted that two staff members had only one reference each on file. In discussions with the acting manager an explanation was given. However it was agreed that the missing references would be chased up. The home provides an induction/foundation training programme for new staff, which follows the TOPSS England guidance. TOPSS England became ‘Skills for Care’ in April 2005 and produced a new set of Common Induction Standards (CIS) designed to be met within a twelve-week period. The home is advised to introduce the new standards for all newly appointed care staff. At the time of producing this report the home has confirmed in writing that the Common Induction Standards have been introduced. The staff training plan demonstrated that statutory training is regularly updated. Care staff supported the fact in discussions with the inspector. It was noted that dementia awareness training is included as part of the training programme. One of the visiting professionals spoken with felt staff would benefit from dementia training in light of the mental frailty experienced with some of the residents. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 21 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 and 38 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not had a registered manager for approximately two years. This situation is considered unacceptable. Since the last key inspection an acting manager has been appointed, and action taken to address shortfalls identified at that inspection. The home has developed effective quality assurance systems for measuring its performance based on seeking the views of residents, representatives and stakeholders. The home has no involvement with residents’ financial affairs other than to provide a facility for safekeeping money or valuables on request. While policies, procedures and staff training ensure so far as is reasonably practicable the health, safety and welfare of residents and staff an electrical inspection is required to be carried out by a NICEIC qualified contractor. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 22 Additionally, self-closing fire doors must only be held open with a mechanism approved by the Fire Safety Officer. EVIDENCE: On the day of the site visit the inspector had an opportunity to speak with the proprietor who visited the home during the morning. The subject of the lack of a registered manager was discussed. The proprietor acknowledged the problem and explained the difficulty of appointing a manager for a small home. He said that a new manager had been identified but was not likely to be appointed until the end of August/ beginning of September, when the new build was nearing completion. He stressed his commitment to a positive turnaround of the service, which will be fully realised with the new facilities in the development and the appointment of a manager. While it is in no way a reflection on the abilities of the acting manager, who appears on the evidence to have done a competent job in managing the home since being appointed, the lack of a registered manager for this length of time is unacceptable, as it influences the quality of care and has the potential for putting residents at risk. Demonstrative action must be taken to meet the requirement of registering a manager or enforcement action will be taken to ensure compliance. The acting manager produced a comprehensive quality assurance document, which showed that positive action had been taken, not only to seek the views of service users, but also to act on the information gained to improve the service. Action included: • • • • • Regular residents’ meetings with minutes taken. Visitors and stakeholders are encouraged to fill in questionnaires, which are prominently displayed in the hall. Results are evaluated and action taken. Policies and procedures are reviewed and updated. A development and improvement plan produced for 2006. The inspector looked at the arrangements for safeguarding residents’ monies and valuables and found the system to be satisfactory. The home’s pre-inspection information signed by the acting manager confirmed that policies and procedures were in place to ensure safe working practices in the home. All care staff undertake statutory training, which Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 23 includes health and safety, food hygiene, manual handling, infection control and first aid, which are updated on an ongoing basis. A sample of records was viewed including accidents, fire logs, gas certificate and public liability insurance, all of which were in good order. There was no evidence that an electrical inspection carried out by a NICEIC qualified contractor was still current and this needs to be addressed. Additionally, it was noted that the door to one resident’s room and the selfclosing fire door between the kitchen and the dining area were wedged open. If it is important for these doors to remain open, they must be risk assessed, and advice sought from the fire safety officer as to an approved means of holding them open. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 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 x x 3 x 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 3 x 3 x x 2 Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 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 OP9 Regulation 13 • Requirement Correction fluid must not be used to amend errors in recording. • To produce protocols for the administration of PRN medication. To provide liquid soap and disposable towels in all areas of communal hand washing in order to minimise the risk of cross infection. A minimum of 2 written references must be obtained before appointing a member of staff. The home must appoint a manager and an application for registration must be submitted to the Commission. (This requirement remains outstanding from 3 previous inspections). Self-closing fire doors must only be held open with mechanism approved by the Fire Safety Officer. Timescale for action 18/08/06 2 OP26 13 18/08/06 3 OP29 19 Sch.2 31/08/06 4 OP31 8 31/08/06 5 OP38 13 31/08/06 Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 26 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 Refer to Standard OP18 OP30 Good Practice Recommendations To update the home’s adult protection policy and procedure with reference to the Commission for Social Care Inspection (CSCI). To introduce the new Common Induction Standards for all newly appointed care staff. Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Rosewood Care Home DS0000011616.V294294.R01.S.doc Version 5.2 Page 28 - 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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