Inspection on 30/01/07 for Rosewood Court

This inspection was carried out on 30th January 2007.

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 10/05/06

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 Liz Cuddington Key Unannounced Inspection 10:00 30th January & 7th February 2007 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.V325553.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 Court DS0000034033.V325553.R01.S.doc Version 5.2 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 *** Post Vacant *** 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.V325553.R01.S.doc Version 5.2 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 17TH October 2006 Date of last inspection Brief Description of the Service: Rosewood Court provides care for up to eighty older people diagnosed as needing residential or nursing care, including those diagnosed with dementia. The home is purpose built. The size and layout meets current minimum standards. All bedrooms 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. Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group, for example ‘Choice of Home’, and ‘Health and Personal Care’. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers these outcomes to the people who use the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded in the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The purpose of the inspection was to assess how well the home is providing care and support services to the people who live there. Two inspectors spent eight and a half hours at the home on the first day, and one inspector returned for a second visit and stayed for four and a half hours. The methods we used to gather information included conversations with residents, relatives and staff, tracking the way care is provided, examining records and touring the home. Since the last inspection on the 17th October 2006 the Commission for Social Care Inspection has been informed of a complaint made by the relative of a resident. The home has investigated the complaint satisfactorily. Although there are still areas for development, the home has made significant improvements since the last inspection and the service offered is of a higher quality. We would like to thank the ladies and gentlemen who live at Rosewood Court, their visitors and all the staff, for their welcome and hospitality during the inspection and for taking the time to talk to us. What the service does well: The residents and their relatives told us, that the staff are kind and we saw that they treat the residents with dignity. The pre-admission assessments are thorough. There are drinks and snacks available throughout the day and fresh fruit is offered with the mid afternoon drink. The home’s complaints and adult protection procedures are clear and understood by the residents, relatives and staff. The staff training programme is very comprehensive and is gradually resulting in a better quality of care for Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 6 residents. The recruitment procedures are safe and all the necessary checks are carried out. Staff disciplinary procedures are thorough and effective. The Commission for Social Care Inspection is kept informed of all significant events and updated on the progress of any areas of concern. The home is clean and hygienically maintained and there is a programme of refurbishment. The manager’s leadership style is clear and the staff who commented said that the home is better run than before her appointment. What has improved since the last inspection? What they could do better: The medication practices must all be safe and follow professional guidance. Activities to suit all individual needs should be available, especially when this is a need identified in a resident’s care plan. Residents who wish to eat in the lounge or their bedroom should not be eating from a low coffee table, but from a table which is properly laid and of the right height. If residents need assistance at mealtimes, this should be noticed by care staff and an offer of help made. The care staff should respond appropriately to residents’ preferences concerning the television, music and other matters that are outside their control. Maintenance jobs in the home need to be dealt with more quickly. All the bathrooms should be in a suitable condition to be used and not used as storage rooms. All residents should have access to their bedrooms. If bedrooms are locked and the resident does not have a key, there must be agreed and documented reasons for this. Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 7 Clinical waste must not be left in places other than the designated, safe storage areas. The unused medicine collection system should be reviewed to prevent a build up of large quantities of unused medicines. The laundry needs a separate wash hand basin, to help prevent the spread of any infection. Residents clothing should be taken to residents’ rooms and put away without becoming creased in the process. When there is a staff shortage, especially when annual leave has been planned, cover should be arranged to maintain the correct staffing numbers and experience levels on each unit. More care staff need to complete their National Vocational Qualification (NVQ) in care. Additional supernumerary time should be allocated to the Deputy Manager to provide support to the home’s Manager to run the home and raise and maintain the standards of care and support for residents. 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. The summary of this inspection report can be made available in other formats on request. Rosewood Court DS0000034033.V325553.R01.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 Rosewood Court DS0000034033.V325553.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 does not apply Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission assessment process is thorough. EVIDENCE: Before offering a care service the manager and another member of staff visit the person to discuss their needs and to help them make a decision about whether the home can meet those needs. The pre-admission assessments are kept in the care plans and are used to produce a draft care plan. A Social Services’ needs assessment is also used to provide information and relatives are involved where this would be helpful. Prospective residents and their relatives are welcome to visit the home before making a decision. When the resident has been staying at Rosewood Court for about six weeks a review Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 10 takes place to decide if the resident and their relatives, if they are involved, are satisfied and that the home can meet the individual’s needs. Rosewood Court DS0000034033.V325553.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The social and health care plans are comprehensive, and most residents or their relatives have agreed to them. The medicines administration systems are not safe at all the units. Residents are treated with respect by the staff. EVIDENCE: We looked at a selection of care records for residents in the different units at Rosewood Court. There was evidence that the care plans are audited and reviewed by the staff each month. The care plans are well set out and information is easy to find. There are plans in place setting out how health, personal and social care needs will be addressed. Risk assessments were done for nutrition, continence, falls, pressure sores, moving & handling and the use of bed rails. One plan included very comprehensive information about managing challenging behaviour. Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 12 Some aspects of the plans should be more detailed, for example the type of incontinence pad should be specified, personal hygiene care plans should have more information about what people can do for themselves and exactly what help they need. There was evidence that the Tissue Viability Nurse had been consulted about pressure sores, wounds are graded and detailed information is recorded. The home does a monthly audit of pressure sore treatment and progress. Most of the care plans showed that the residents and/or their representatives are involved in the care planning and review process. One relative said they had not seen or agreed to a written care plan. There was evidence that other health and social care professionals are involved, where needed, and residents have access to NHS health services. The medicine rooms are internal and can get very hot during the summer. The Deputy Manager said there are plans to relocate the one at Willow. The drug fridge temperatures are being recorded. The Deputy Manager said that training on the management of medicines had been organised for nurses and care staff for the week after the inspection. The Medicines Administration Record (MAR) charts were accurately completed at one of the units. At another unit there were signatures missing from the charts and there was no ‘brought forward’ system for those medicines that are for use only when needed, such as paracetamol. Not all of the medicine quantities tallied with the amounts that had been administered and signed for. Looking further I found that one of the medicine bottles had been broken and the tablets put into an open pot with a note giving the details. This is an unsafe and potentially dangerous practice. The home’s manager was not aware of this and dealt with the situation immediately she was informed. The clinical waste bins used to dispose of unused medicines were very full. The Manager confirmed what other staff told us, that they have to phone the contractor when they are full and they want the bins to be removed. The company should reconsider this arrangement to prevent a build up. The residents were wearing their own clothing, and looked comfortable and warm, although some ladies were not wearing stockings or tights. The relatives of one resident confirmed that their Mother always wears her own clothes. The staff approach was calm and they treated residents with respect and maintained their dignity. Relatives confirmed that staff are kind to the residents. Relatives and other visitors are always welcome. Rosewood Court DS0000034033.V325553.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the range of activities available, but more needs to be done to meet all the residents’ needs. Mealtime arrangements, drinks and food choices are generally good, but need some improvement. EVIDENCE: The staff said there are social profiles in the care plans and when they can they sit and talk to residents about their interests. One member of staff said she sits with people and talks about their life, looks at their photo albums or sings and plays games with them. There was information about activities on the notice boards on each unit and in the lifts. The activities organiser said they were different for each unit. There was a notice in each lift about a service for “all religions”, although one lady said her denomination is not catered for. There was also a notice, advertising a clothing sale in February. Two relatives said they felt that more activities are needed. Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 14 Twenty people recently went to St George’s Hall in Bradford and about 14 people visited Millstones in Harrogate. There are fund raising efforts to help pay for activities and the home pays for an entertainer to visit the home about every six weeks. Organising enough different activities to suit such a large and diverse group of people is a complex task for one person to manage. The activities co-ordinator said that residents are generally reluctant to go onto other units for activities. A game of bingo was held in one of the dining rooms on the first day of the inspection and some residents from other units did go along. One resident’s care plan specifically says that activities should be available to occupy the person, but no involvement in activities was recorded on the plan. In the lounge at Willow the television was on very loud all afternoon, even when the programme changed to children’s television. A resident asked one of the staff to turn it off, but the carer said other people might be watching it and did not turn it off. There was only one other resident in the lounge at the time. The other resident said he had enjoyed listening to music tapes the day before, but the carer did not follow this up. The channel was changed a little while later. When residents are unable to control their own environment it is essential that staff consult with residents and follow their wishes. There were no menus in the dining room on Willow. In the other units the weekly menus were not easy for people to read. The manager said she was having daily menus printed for all the dining rooms. Staff said that the residents are asked what they want for lunch when they get up in the morning. There are two choices at lunchtime and the food comes from the kitchen on a hot trolley. When asked, the staff on Aspen did not seem sure what the lunchtime meal was. One resident who did not like what was on his plate was given something different. Some residents were eating at tables in the lounge, although it was not clear why. It looked uncomfortable, as the tables were low and were not placed directly in front of the resident. If residents choose to eat in the lounges or their bedrooms they should be provided with a properly laid table of the correct height. One person did not have a knife to cut her meat. A carer asked her if she was going to eat her lunch but did not offer to help cut up the meat. On Cedar unit we saw the staff giving out afternoon tea with biscuits and pieces of attractively cut up and arranged fresh fruit, which the residents enjoyed. The teatime meal is served at about 4.30pm. Included in the choice were fish fingers and chips, and a curry for one resident. Staff said there is a cooked tea every evening. We saw drinks being offered during the day. Rosewood Court DS0000034033.V325553.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and adult protection procedures are clear and understood by staff, service users and relatives. Complaints and adult protection issues are dealt with effectively. EVIDENCE: Information about how to make a complaint is displayed on the wall in the entrance hall. The people who commented said they knew how to make a complaint. One person said they had made complaints in the past, but nothing had been done. However that was before the present manager was appointed, and the situation has improved since then. Before the inspection a complaint made to the home was dealt with effectively by the manager and Operations Manager. All staff receive training on adult protection and what to do if they suspect in incident of abuse or poor practice has occurred. Staff know how to put this training into practice. Rosewood Court DS0000034033.V325553.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and well decorated and improvements to the environment have been made. General maintenance, use of bathrooms, care of clothing, quality of bedding and hygiene practices need to be improved. EVIDENCE: The home comprises four separate units. Aspen is for residential care, Willow is for people who need nursing care, Rowan is for people who need residential dementia care and Cedar, which is for people who need nursing dementia care. The overall impression was that the maintenance routine within the home is not as good as it should be. For example, there seemed to be a problem with the light bulbs. The manager said she was aware of this and home was now Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 17 using a different type. The light fitting in one en-suite toilet was unsafe and hanging from the ceiling. We saw evidence of recent refurbishment and redecoration throughout the home and the lounge on Willow has new armchairs. Small tables near residents’ armchairs are now in place. All the bedrooms are single rooms. They are a good size and all have an ensuite toilet and washbasin. All the bedroom doors have door locks fitted. On Rowan and Cedar units all the bedroom doors have been decorated to look like house doors and street names have been put up. They are all painted in different colours and fitted with brass letterboxes and doorknockers. However, the bedroom doors are kept locked so residents do not have independent access to their bedrooms. How this could be improved was discussed with the manager. All the bedroom radiators have protective guards fitted and window restrictors are fixed. Several bedrooms did not have nurse call bells connected to the system; the manager said more had been ordered. Most of the bedrooms were personalised with the resident’s belongings, although some were very sparse. There were no towels or flannels in the en-suite toilets when we looked in the morning and the afternoon. The manager said they are put out later in the day. Staff told us that some residents use their rooms to wash before lunch and would then need a hand towel. Each unit has two bathrooms with fittings to make them suitable for assisting residents to bathe, including newly fitted ceiling track hoists. In most units one of the bathrooms was kept locked and used to store hoists, ladders, a mattress and other equipment. The bath enamel was badly damaged in one bathroom. In one bathroom there was no bath thermometer, no toilet seat, communal soap, and no paper towels. The light was not working in one bathroom. The home is generally kept clean, hygienic and well decorated. The bathrooms that were being used were clean and attractively decorated. The shared toilets are a good size but there were no shades fitted to the ceiling lights. On some units there were no hand towels in the shared toilets. It may be helpful to some residents if signs were put on the shared toilet doors. We saw some bedding that was of poor quality and some pillows that were lumpy. Some of the beds had been badly made, and some were not as clean as they should be. The clinical waste bins and laundry skips are locked in the storerooms. One of these rooms had no light bulb. On one unit soiled trousers, knickers and a pad had been left on the floor outside the storeroom. Used protective gloves had Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 18 been left on the surface in one of the bathrooms. These practices are unhygienic and could contribute to the spread of infection. The link corridor on the first floor has been very nicely decorated with a bar in corner. It is used for social events and for residents and their visitors to spend time together. The laundry is small for the size of the home and there is not enough space to separate clean and dirty washing effectively. It is well equipped with washing machines and driers, but does not have a sink for the person working there to wash their hands. On the units we saw clean laundry piled on trolleys waiting to be put away. Some items had the resident’s name on them, some had room numbers and some clothing was not named at all. When we looked in the bedrooms some of the shirts and blouses were creased, even though they had been ironed, and some bedding was also creased. This was not improved by clothing being packed tightly in some of the wardrobes. The enclosed gardens looked empty, although the manager said a lot of work had already been done and we saw that trees had been pruned. The gardener has plans for gardens and was due to start planting in two to three weeks’ time. Rosewood Court DS0000034033.V325553.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are not always adequate. Staff recruitment procedures are safe and there is a comprehensive staff training programme. EVIDENCE: On the morning of our visit there were only two care assistants and the team leader on Willow. There are usually three care assistants on both the morning and afternoon shifts. The rota showed they were short staffed because one care assistant was on holiday; it was not clear why this shortfall had not been covered. The unit’s team leader was doing induction training with a bank nurse who had started that day, and was clearly under some pressure. Rowan was short of one care assistant on the morning of the visit; the staff said there is usually a senior and 3 care assistants on the morning shift and a senior and 2 care staff in the afternoon. One of the care assistants was new and usually worked on another unit. Although she had started a BTEC in care at college, and said she had done fire safety and moving and handling training, she had not had any dementia care training. Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 20 We looked at a cross section of staff files. They all included completed application forms, interview records and two written references. There was evidence that they had all applied for Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) list checks. One did not have a POVA first check for her current post with the organisation, although there was one from her previous post. The other files showed that POVA first checks had been obtained before the person started work. None of the files included confirmation that satisfactory CRB checks had been received. The manager said that the organisation’s head office send through a confirmation notice once a CRB check has been received. The documents of staff from overseas are checked to make sure they have the right to live and work in the UK. The staff that we spoke to said there is a lot of training for them and all said they enjoy the training and find it valuable. They said that the manager would organise any training they need. The manager said that eleven staff had recently done dementia care training and eleven more were due to start soon. The manager has a regular programme of staff training when a selection of courses is available during one week of every month. The Deputy Manager delivered abuse training to twelve staff at the home in the week of our first visit. The Deputy Manager will also be delivering training on care planning. The staff files and training records showed that new staff follow a recognised induction training programme. From a total of thirty-seven care staff, seventeen have achieved a National Vocational Qualification (NVQ) in care and ten care assistants are working towards the qualification. Rosewood Court DS0000034033.V325553.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home has improved since the last inspection, resulting in a better service. EVIDENCE: The Manager has the qualifications and experience to manage the home effectively. The Manager has applied for registration with the Commission for Social Care Inspection. This was being processed at the time of the inspection visits. Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 22 Each unit has a designated team leader, although the post on Cedar is not filled at present. The Deputy Manager is one of the team leaders, and she has some supernumerary hours to provide training and to cover when the Manager is on leave. The organisation’s regional Operations Manager visits the home every week, and is available at other times when needed. The manager is clearly working very hard to bring about improvements to the home, for the benefit of the residents and staff. However, this is a large and complex home and the management responsibilities are equally complex. It may benefit the home, and help the Manager to raise and maintain standards, if the Deputy Manager’s role includes more supernumerary time to take on some of the day-to-day management tasks. The nursing, care and anciliary staff that we spoke to said the home is much better run since the present manager took over; they said she is very approachable and staff morale is much better. Residents and relatives meetings take place on each unit; two had happened on each unit since the last inspection and more were booked for February. The Manager has a ‘clinic’ on Tuesdays where she is available to see residents or relatives, but she is also available at other times by appointment. Staff receive one to one supervision with a senior member of staff every two months. Staff meetings are held at least every three months; there are both general meetings and unit meetings. There are also separate meetings for the various staff groups and special staff meetings are held to deal with specific issues. Some residents’ money is kept securely for them and they have access to it whenever they wish. Records of all transactions are kept. There is a range of quality assurance systems in place to assess the views of the residents and relatives. The questionnaires are sent out annually and are returned to the organisation’s head office for analysis. It was not clear to me how the information is used for the benefit of the home. Quality audits are carried out each month and the Operations Manager completes a monthly report. I visited the kitchen. The refrigerator, deep freezer and hot food temperatures are checked and recorded on most days. The large chest freezer contained unsealed, unlabelled food packages as well as loose items of food in the bottom of the freezer. All food in the refrigerators and deep freezers should be re-sealed and labelled with the date after opening. The kitchen is clean and hygienically maintained. The front door is sometimes left unsecured when the receptionist/administrator has to leave her desk. One relative said he had often had to wait up to ten Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 23 minutes in the evening for someone to answer the doorbell. It might be helpful if an alternative system linked to each separate unit was installed. Rosewood Court DS0000034033.V325553.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 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 X 3 3 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Rosewood Court DS0000034033.V325553.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 OP7 Regulation 15(2)(c) Requirement Where possible the care plans must show that residents or their representatives have been involved in the development and review of their care plans. (This requirement remains outstanding since 30/11/05, 30/04/06, 10/05/06 and 17/10/06.) The registered person must make sure medication is recorded, stored and handled safely, in accordance with the Royal Pharmaceutical Society’s guidance. (This requirement remains outstanding since 17/10/06.) The registered person must make sure all residents have access to a range of suitable activities, which meet their needs. The registered person must make sure that there are adequate assisted bathing facilities available to residents. DS0000034033.V325553.R01.S.doc Timescale for action 30/06/07 2. OP9 13(2) 31/03/07 3. OP12 16(2)(m) and (n) 30/06/07 4. OP21 23(2)(j) 30/04/07 Rosewood Court Version 5.2 Page 26 5. 6. OP26 OP26 16(2)(j) 16(2)(j) 7. OP27 18 (This requirement remains outstanding from 10/05/06 and 17/10/06.) Dedicated hand washing facilities in the laundry must be provided. Staff must put all soiled clothing and clinical waste in the designated, secure storage areas. The registered person must make sure that at all times there are enough suitably qualified, competent and experienced people working at the care home, to meet the needs of the service users. (This requirement remains outstanding since 31/10/05, 10/05/06 and 17/10/06.) The registered person must make sure that sufficient supernumerary time is available to senior staff, including the Deputy Manager, to allow managerial tasks to be completed effectively. (This requirement remains outstanding from 17/10/06.) The registered person must make sure the main door is secure when unattended. (This requirement remains outstanding since 17/10/06.) 30/06/07 31/03/07 31/03/07 8. OP31 10 and 24 30/04/07 9. OP38 23(1) and (2) 31/03/07 Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP15 OP19 OP21 OP28 OP38 Good Practice Recommendations Residents who wish to eat meals in the lounge or their bedroom should be served on a table of a suitable height. Routine maintenance tasks in the home should be completed with minimal delay. Shared toilets should be clearly marked. The registered person should make sure that at least 50 of the care staff are qualified to NVQ level 2 by 31st December 2005. Opened food packages need to be sealed and date labelled. Rosewood Court DS0000034033.V325553.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V325553.R01.S.doc Version 5.2 Page 29 - 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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