Inspection on 10/05/06 for Rosewood Court

This inspection was carried out on 10th May 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.

Other inspections for this house

Rosewood Court 30/01/07

Rosewood Court 21/03/06

Rosewood Court 18/11/05

Rosewood Court 27/04/05

Rosewood Court 07/09/04

Rosewood Court 22/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosewood Court Shakespeare Close Butler Street East Bradford BD3 9AR Lead Inspector Karen Westhead Key Unannounced Inspection 10th May 2006 09:15 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 Court DS0000034033.V292725.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. Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rosewood Court Address Shakespeare Close Butler Street East Bradford BD3 9AR 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) 01274 308308 01274 308307 Southern Cross Healthcare (Kent) Ltd Care Home 80 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (41), Old age, not falling within any other of places category (40), Physical disability (1) Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the category of PD be used for the service user named in the application signed on 5 October 2004 The place for DE is for the named service user only. One of the DE(E) places is specifically for the person named in the variation application dated 17.2.06 21st March 2006 Date of last inspection Brief Description of the Service: Rosewood Court provides care to eighty older people diagnosed as needing residential and nursing care including those diagnosed with dementia. The home is purpose built. The size and layout meets current minimum standards. All rooms are single, with an en-suite toilet and washbasin. The home is close to Bradford city centre and is well served with public transport. There is level access into the home and two passenger lifts. The building is split into four specialist units, each catering for up to twenty people. There are two enclosed garden areas. Prospective residents are provided with ample literature prior to admission to inform them of the services and facilities provided at Rosewood Court. Information about the fees and any additional charges was not available at the time of writing this report. The pre-inspection questionnaire had not been returned to the office in time to allow the information requested to be used. Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection before 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. The visit was unannounced. Two inspectors were present and the visit started at 9.15am and finished at 6.30pm. Feedback was given at the close of the visit of matters, which required urgent attention. Full feedback was given on 16th May 2006 by telephone once the information gathered had been analysed. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. The last inspection of this service was on 21st March 2006. At that time nineteen requirements and three recommendations were highlighted. The report was drafted and sent to the service provider. The deadline for a written response remains valid. During the course of the visit, the inspector spent a large proportion of time speaking with residents, visitors, staff members and other professionals. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. Inspectors also spent a good proportion of their time talking to residents, staff and visitors. Residents who were unable to comment on their experiences were observed. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. One comment card asks questions about the inspection process and the way the inspectors carried out their duties. After completion these are returned to the CSCI. What the service does well: Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 6 One visitors comment card and three residents questionnaires were returned to the CSCI office. One was returned incomplete with an explanatory note. All the comments were positive. These are listed in the section headed Daily life and Social Activities. Prospective residents are given enough information to help them make an informed choice about Rosewood Court. Resident’s health care needs are met. Residents are given ample opportunities to have refreshments and snacks inbetween scheduled meal times. Residents are helped to make choices and where appropriate retain control over their lives. Complaints are taken seriously and dealt with appropriately. Financial arrangements are well organised and safeguard the personal monies belonging to residents. The rolling programme of refurbishment continues and the home is benefiting from the improvements. Most areas of the home were found to be clean and tidy. Staff were described in positive terms by visitors and residents. An appropriate management structure is now place, following the appointment of a manager. Safe working practices were observed during the visit. What has improved since the last inspection? What they could do better: Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 7 Some progress has been made towards meeting the requirements and recommendations outstanding from previous inspections. Staff and managers are committed to raising the standards and this should be borne in mind when reading this report. However, there is still work to be done to make sure the home is complying with the regulations. Requirements and recommendations can be found at the end of this report. The registered provider must take urgent action in order to address the requirements and make sure that residents in the home receive a good standard of care and that the home is run in the best interests of the residents. Further regular monitoring visits will be made to check that progress is being made. Legal enforcement action may be considered on issues that have consistently remained unresolved or are of serious concern. 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 Court DS0000034033.V292725.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 Rosewood Court DS0000034033.V292725.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 and 5 Prospective residents have sufficient information to help them make an informed choice about Rosewood Court. No one moves in without having had his or her needs assessed. All admissions are subject to a trial period and review process. EVIDENCE: Three of the care plans seen had copies of social workers single assessments. There were also completed pre admission draft care plans, that were done as part of the pre admission assessment process. The home provides a wide selection of information relating to the services and facilities provided. Therefore giving a resident an idea of what to expect on admission. Residents are invited to visit the home before being admitted for a trial period. This is determined on an individual basis, according to the circumstances and needs of each resident. It was clear that some trial periods are extended if necessary in order for the resident to be sure about their decision to stay. Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 10 Two visitors said that somebody had visited their relative prior to them being admitted and had made notes about their requirements. They said that they had been to look round before making the decision for their relative to move in and that their questions had all been answered and they had taken a brochure away with them. One visitor said their relative had been living in the home for a few weeks and they were satisfied with the services provided. Rosewood Court DS0000034033.V292725.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 and 10 Residents and their representatives are not always party to completing care plans. Some care plans were not fully completed to include all aspects of individuals care needs. Not all staff address residents in a respectful and dignified way. Resident’s health care needs are met. The homes policy on reordering medication does not protect against potential errors or fraud. EVIDENCE: Five files showing how care was to be provided (care plans) were looked at across the four separate units. Two care plans were seen on the dementia units. One was for a resident who had been admitted a few weeks ago, their relative said people had spoken to them but that they were not sure if this was part of the care planning process. In addition, three other care plans were examined on the remaining units. Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 12 None of the records showed that residents or their relatives had been involved with the writing of the care plan. The care plans showed that forms were in place to carry out healthcare and risk assessments such as: a) Moving and handling b) The risk of developing pressure sores c) Nutritional risk assessments d) Dependency assessments. Where these assessments showed that the resident had particular needs information was included in the care plans. The care plans gave different styles of information, which were not always detailed about the individual’s needs, preferences and abilities. One of the senior care assistants who had started a training course about dementia care said that they now had a different view of looking at the person with dementia care needs and was making sure that the care plans were more detailed and informative about the individual. Not all identified needs were detailed in the plans seen. One of those seen did not give any information about how to look after an injury that needed dressing and attention from the district nurses, how to protect their skin which was fragile and bruised easily or how to help them settle and rest at night. One care plan included documentation relating to the incidence of bruising and diagrams showed where bruises were evident. However, this was not dated or signed and was not referred to in the daily living notes. Two entries in one residents daily living notes referred to medication being given late due to an emergency in the home and that the resident had had a dispute with a care assistant. Neither record had been explored further with those concerned. A letter in one of the care plans showed that the resident had been allocated to a new GP. Staff said that wherever possible residents stayed with their own doctor but if they moved out of the doctor’s area they would have to register with a new surgery. Staff were seen giving medication to residents. Safe procedures were being followed. The medication administration records looked at had been properly filled in. Staff on the residential units said they had done certificated courses about dealing with medication. The nurses said that they had done medication training in the last three years. Staff on the residential and dementia nursing units said that when they order repeat prescriptions some of the surgeries do not send back to them to be signed and checked but have them collected by the dispensing chemist. This sometimes means that tablets needed are not always available. Prescriptions should be seen in the home before they are sent to the chemist to make sure Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 13 that the correct medications have been prescribed and to sign them in order to reduce the risk of fraud. Staff were seen knocking on residents’ room doors before entering. Relationships between staff and residents on most units were friendly and respectful. But on the dementia nursing unit the staff did not relate to the residents as well as they did to each other. One member of staff was helping a resident to eat breakfast and stood at the side of them while they did so going off to attend to other residents during the meal. Some residents said that staff did not treat them with respect and dignity and spoke to them in a disrespectful way. They said that some staff used foul language in their hearing and one said that they had been shouted at by one of the carers. Rosewood Court DS0000034033.V292725.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 and 15 Resident’s cultural and religious needs are not fully met. Social and recreational needs are being met in a variety of ways. Residents are given ample opportunities to take refreshments and snacks inbetween scheduled meal times therefore meeting their nutritional needs. Residents are helped to make choices and where appropriate retain control over their lives. EVIDENCE: The home has a mix of staff from different cultural backgrounds. The home has an equal opportunities policy in place for staff but information about equality and diversity for residents could not be found. Staff said that they would identify individual’s cultural and religious needs in the care plans, but there was no written evidence to support this. Visitors said that they were able to visit at any time and that staff made them feel welcome. They said that they were satisfied with the care given to their relatives and that the staff were kind and caring. Despite the matters raised about the ways some residents were being supported with eating, food provision is good on the whole. Meals are Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 15 presented in a calm and relaxed way. Menu choices are available and staff were seen to give residents time and the opportunity to choose what they would like to eat. Food and snacks are prepared and presented in a way, which allow residents with difficulties to access them and enjoy them. Examples of this were seen, including specialist crockery and cutlery. The visitors comment card confirmed: • they were welcomed into the home, • able to visit their relative in private, • were kept informed of important matters affecting their relative, • felt there were sufficient staff on duty, • they were aware of the complaints procedure, and • they were satisfied with the overall care provided. Two • • • • • • • • questionnaires from residents confirmed: they had received a contract, had been given enough information about the home before moving in, they always or sometimes received the care and support needed, staff usually listened and acted on what they said, staff were sometimes or usually available when needed, they always received medical support when required, that there were always or sometimes activities they could take part in, that they sometimes or usually liked the meals – one resident felt the meals could be a lot better and more choices should be made available, • that they always knew who to speak to if they were not happy, • the home was always or usually fresh and clean. Neither resident wished to speak further to an inspector. Rosewood Court DS0000034033.V292725.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 and 18 Complaints are taken seriously and dealt with appropriately. Staff have not received training around adult protection therefore it is not clear that residents would be protected from abuse. Financial arrangements are well organised and safeguard the personal monies belonging to residents. EVIDENCE: There is a complaints procedure, which is included in the Statement of Purpose. Two visitors said they were not aware of it but that they would speak to the manager or the person in charge if they had any concerns. One other visitor had made complaints in the past and these had been dealt with appropriately by the company. One complaint has been made to the home since the last inspection. The operations manager had investigated this and sent a response to the complainant. Staff said they had not received training about abuse and adult protection but that they would not hesitate to report concerns about how people treated residents to the person in charge. Financial arrangements are well organised with procedures in place to ensure all transactions are recorded and audited. The home employs an administrator Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 17 who spent time showing the inspector the systems in place. One matter requiring attention was brought to the attention of the project manager who agreed to rectify the situation, which had been an oversight. Rosewood Court DS0000034033.V292725.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, 21 and 26 The rolling programme of refurbishment continues and the home is benefiting from the improvements. Most areas of the home were clean and tidy. Two of the bedrooms had an underlying odour of urine. Some work is required to make sure facilities are safe and appropriate. The outstanding situation with the laundry provision creates an opportunity for cross infection. EVIDENCE: A requirement was first made at the inspection in April 2005 that plans be put in place to improve the laundry facilities by 31st March 2006. The area is small for the size of the home and the amount of laundry generated, it does not allow for the adequate separation of clean and dirty linen and there is inadequate storage space for laundered items. This increases the risk of cross infection. The manager was advised to contact the infection control nurse for advice on how to reduce the risk of cross infection. The positioning of the Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 19 dryers also presents a moving and handling risk to staff when using them. It was confirmed that a survey of the laundry area had been done and an estimate for the costs involved. However, no decision had been made about whether the work required would be approved. This is still an unsafe area for staff to work in. Soiled linen has to be stored in the staff toilet because there is no room for it in the laundry. A programme of redecoration is underway. The reception area and communal areas of the general residential unit have been done and the decorators were working on the corridors of the residential dementia unit. The project manager said that the décor of both dementia units would be made appropriate for people with dementia. There had been a marked improvement in the general appearance of the home. Additional pictures, plants and ornaments had been provided. One room had been provided with a piano. The garden areas were not being used. Only residents from the general residential unit were sitting outside on the patio area at the front of the building, staff said that this was their choice as they could see more of what was going on rather than being in the garden area. The project manager is looking at ways to make the enclosed garden areas more appealing. Inspectors were told that the garden furniture, being plastic, was not robust enough for residents. The operations manager agreed to look at this. Each unit has two bathrooms but staff said they only use the one that has the hoist available. At least one bathroom was being used to store unused furniture and a toilet was being used to store soiled laundry in bags, waiting to be picked up. The nursing units have an assisted shower. Staff on the residential units said that they take residents to the nursing units if they want a shower. The provision of bathing facilities needs to be reviewed. To make sure there is an adequate number of bathrooms in service and that the facilities meet the needs of the residents accommodated. Some of the bathrooms were lockable using star locks or bolts. The reason for this must be explored and if required an appropriate risk assessment must be completed to make sure potential risks can be minimised. Most areas of the home were clean and tidy. Two of the bedrooms had an underlying odour of urine. Domestic staff were busy cleaning rooms but there is only one carpet shampooer for the whole building and it is difficult for them to clean all carpets that get wet or soiled. It is recommended that an additional shampooer be made available. Resident’s bedroom doors are kept locked during the day. The reasons for this were explained but this limits choice for residents to use their room during the day. The management team should consider ways of overcoming this. Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 20 The nurse call system is available to residents. This was tested twice on the visit and responses were good. Staff attending cancelled the bell at source. There were no comments from residents to suggest there is a delay in staff attendance if they summon help. The manager monitored the log generated from the system. However, the time on the panel was incorrect and needed resetting to ensure accuracy. A fitted carpet, leading to one sitting area needs attention due to fraying. It is acknowledged that this area is for recarpeting as part of the refurbishment programme. The inspectors will be pleased to see the proposals for the connecting corridor brought to fruition. This underutilised area could be of benefit to residents. Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 21 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 Staffing levels do not guarantee that the needs of residents can be met. Staff have not received appropriate training and there is a risk that residents needs will not be met. Staff were described in positive terms by visitors and residents. EVIDENCE: Three members of staff were part way through a dementia training course ‘Yesterday, today and tomorrow’. Two of them said that they had found this very useful and it had made them rethink the way they were looking after people with dementia. When staff were asked what could make the home better they said that access to appropriate training and improving communication in the home were the two main issues. The second point relates to the problems with staff for whom English is their second language. They said that this would make the experience of living in the home better for residents. This point was also raised by visitors during discussions with the inspectors. It should be noted that there has been an improvement in this area and the manager was monitoring the situation in relation to the effective running of the home. Notwithstanding this important point, the established staff team were described as ‘brilliant’ and ‘hard working’ by both residents and visitors. Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 22 A social worker and doctor were visiting residents during the inspection. They made positive comments about the staff and the care provided. They confirmed they saw residents in private and that they were able to work with the staff in a professional way. The doctor said he was called in when necessary and staff were proactive in contacting him and did not wait until a situation became critical. He gave examples of when staff had dealt with the final stages of a resident’s life and done so in a professional and dignified manner. During discussions with staff throughout the course of the day inspectors were told that a member of staff, who worked as a domestic, was also being deployed to carry out caring tasks when the home was short staffed. This was later confirmed by senior staff. It is not acceptable to use staff to carry out duties for which they are neither trained nor experienced in. The manager confirmed that this practice would cease forthwith. Staff have not received appropriate training and there is a risk that residents needs will not be met. Following the last three inspections, a requirement has been made that the staffing levels must be reviewed taking into account the needs and dependency levels of the residents. This has not yet been done. Staff said that staffing levels had remained the same. It was clear that the needs of residents vary on each unit and that the standard staff allocation was not always appropriate. The implications of insufficient staff allocated to one of the dementia units was highlighted at the last inspection. Appropriate risk assessments and care plans were in place for a resident at risk of falling. These showed that the resident did not sleep at night and liked to walk around the unit. At these times they needed 1 to 1 attention from staff. This had been identified at the last inspection and remains unchanged at this visit. Staff said that requests had been made to head office for increased staffing at night but they had been turned down. The resident therefore is still at risk of falling. The requirement about making sure that staffing levels are appropriate to the physical, social and psychological needs and numbers of residents living in the home has been carried forward. Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 23 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 An appropriate management structure is in place therefore staff are receiving guidance and support in their delivery of care. Quality assurance systems are in place giving users of the service an opportunity to voice their views and initiate improvements in the delivery of care. The financial arrangements safeguard the interests of residents. Safe working practices were observed during the visit. EVIDENCE: With effect from the 3rd May 2006 the organisation has issued new quality assurance systems, which includes new audit tools to be used in the home. These include internal audits such as the kitchens, the building, medication, accidents and complaints. The operations manager said that service user Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 24 surveys are being put together and it is hoped to send them out in the near future. A new manager has been appointed and they are being supported through an induction process by the project manager who has been overseeing the home since March 2006 when the last manager left. It is acknowledged that the appointment was made at the beginning of May 2006. It is envisaged that an application to be registered with CSCI will be forthcoming in the near future. Staff said that since the last inspection things had improved in the home and that staff morale was better. They said that staff discipline had improved and that the project manager was taking appropriate action to deal with concerns and situations. The project manager has started a system of formal supervision and 1 to 1’s for staff from April 2006. Records are kept. Rosewood Court DS0000034033.V292725.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 3 X 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Rosewood Court DS0000034033.V292725.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 OP7 Regulation 15(1) and 15(2) Requirement The registered person must make sure that the care plans clearly show how all assessed health, personal and social care needs will be met. These must evidence all actions taken and provide an accurate picture of the service users medical, physical and social well-being. Where possible residents or their representatives must be party to the completion of care plans. This requirement was partially met in 30 November 05. It remains outstanding since 30th April 2006. 2 OP9 13(2) The registered person must make sure that when repeat prescriptions are ordered the correct measures are in place and staff see them before they are sent to the chemist to make sure that the correct medications have been prescribed and they are signed in order to reduce the risk of fraud. The registered person must DS0000034033.V292725.R01.S.doc Timescale for action 07/07/06 07/07/06 3 OP10 12 07/07/06 Page 27 Rosewood Court Version 5.1 4 OP12 12 5 OP19 23(2)(o) make sure that residents are treated with respect and dignity. The registered person must 07/07/06 make sure that residents are able to exercise choice in relation to their cultural and religious beliefs. The registered person must 31/07/06 having regard to the number and needs of service users make sure that the external grounds are suitable for, and safe for use by, service users and that they are appropriately maintained. This requirement remains outstanding from 31 March 06. 6 OP24 16(2)(c) 7 OP21 23(2)(j) The registered person must make sure carpets are fitted correctly to minimise any potential trip hazards. The registered person must make sure that there are adequate bathing facilities available to residents. 07/07/06 07/07/06 8 OP26 13, 16(2)(f) and 23(2)(j) Where locks are used to secure the door, the reason must be justified and a risk assessment in place. The laundry facilities must be 30/09/06 improved in order to provide more room and clear separation of soiled and clean laundry. The registered person must contact the infection control nurse for advice on maintaining best practice until this work has been completed. This requirement remains outstanding from 31 March 06. 9 OP26 16(2)(k) Appropriate action must be DS0000034033.V292725.R01.S.doc 07/07/06 Version 5.1 Page 28 Rosewood Court 10 OP27 18 taken to make sure that the source of bad odours in the home are controlled and reduced. The registered person must make sure that at all times there are enough suitably qualified, competent and experienced people are working at the care home to meet the needs of the service users. A full review must be undertaken of the staffing levels provided on each Unit. The service users dependency level and needs must underpin this assessment. The CSCI must be informed of the outcome and action taken. This requirement remains outstanding since 31 October 2005 and must be addressed as a matter of urgency. 01/07/06 11 OP30 18 The registered person must make sure that people working in the home receive training appropriate to the work they do and suitable assistance, including time off, for obtaining further appropriate qualifications. This must include the Sector Skills Council training targets with regard to induction and foundation training, adult protection and suitable updates on pressure area and wound care and administration of medicines for nurses. The specialist needs of service users must also be taken into account especially with regard to dementia care and dealing with challenging behaviour. The registered person must make sure that all staff can 07/09/06 Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 29 communicate effectively with residents. This requirement remains outstanding from 31 March 06. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations The registered person should make sure that at least 50 of the care staff are qualified to NVQ level 2 by 31.12.05. December 2005. The registered person should consider making an additional shampooer available. The registered person should review the locking of resident’s bedrooms during the day to make sure the occupants are not being denied the opportunity to use the room. 2 3 OP26 OP23 Rosewood Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Court DS0000034033.V292725.R01.S.doc Version 5.1 Page 31 - 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. 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