Inspection on 31/01/07 for Rosewood House Care Home

This inspection was carried out on 31st January 2007.

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

The inspector 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 House Care Home 21/05/08

Rosewood House Care Home 10/12/07

Rosewood House Care Home 03/05/06

Rosewood House Care Home 23/11/04

Rosewood House Care Home 17/08/04

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

CARE HOMES FOR OLDER PEOPLE Rosewood House Care Home 84a Main Road Radcliffe on Trent Nottingham NG12 2BQ Lead Inspector Steve Keeling Key Unannounced Inspection 31st January 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosewood House Care Home DS0000008796.V328547.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 House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosewood House Care Home Address 84a Main Road Radcliffe on Trent Nottingham NG12 2BQ 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) 0115 933 4717 0115 933 2510 sherryseetal@btinternet.com Mr Mukesh Seetul Care Home 17 Category(ies) of Dementia - over 65 years of age (17) registration, with number of places Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users shall be within category DE/E, 1 Named service user shall be within category DE 3rd May 2006 Date of last inspection Brief Description of the Service: Rosewood House is an adapted and extended property sitting in the heart of a residential area of the village of Radcliffe on Trent. The home is registered to provide residential care for up to 17 service users who have Dementia and particular needs associated with their diagnosis. The accommodation spans two floors and there is a vertical lift to facilitate access between these floors for service users. Gardens are to the side and rear of the property and there is a car park to the front. The village of Radcliffe on Trent is a couple of minutes away by car and provides a range of facilities including shops, churches, restaurants, pubs and public transport. The fees charged at the home range from £277 for social service funded residential care to £319 for privately funded residential care. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mr S.A. Keeling conducted the unannounced inspection on the 31st of January and the 1st February 2006 over a 13-hour period. The second date of the inspection was required because of difficulties accessing the required documentation to progress the inspection on the 31st January 2007. The usual method of inspection is case tracking, this is a method of randomly selecting service users within the home and discussing with them their expectations and experiences within the home together with the care practices utilised within the home environment. On this occasion the case tracked service users were unable to fully comment on the care provision at the home due to limited cognitive abilities. The case tracking method examines the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two service users were case tracked. Also as part of the inspection process the acting manager, a member of staff and visitors to the home were informally interviewed to further evidence the quality of care afforded to the service users. A range of additional information, which included the previous judgments and findings, was also used to determine the outcome of this inspection and the report. What the service does well: Pre-admittance assessments are performed to ensure the needs of the service users are identified prior to gaining residency at the home. Service users are afforded stimulating activities within the homes environment. Service users have opportunities to access the local community and to maintain their links with family and friends. Routines are flexible and service users are given choices in their lifestyles. Service users benefit from a varied menu at the home, which is balanced and nutritionally balanced. The home is maintained to an appropriate standard of cleanliness. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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 House Care Home DS0000008796.V328547.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 House Care Home DS0000008796.V328547.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 3 and 6 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. Pre-admittance assessments are performed to ensure the needs of the service users are identified. The home does not provide intermediate care services. EVIDENCE: Through discussions with the acting manager and an examination of service users files the inspector was able to determine that the acting manager performs pre-admittance needs assessments prior to service users gaining residency at the home. The pre admittance assessments evidenced that the residential needs of the service users are identified and documented effectively. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is poor. Standards 7, 8, 9 and 10 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. The case tracking procedure evidenced that the service users identified needs are not effectively addressed through an individual care planning process. Policies and procedures in relation to medication management had not been fully adhered to which could compromise the safety of service users. Practices at the home compromise the service users respect and dignity. EVIDENCE: The care planning documentation examined on the day of the inspection was somewhat disorganised and bulky. The care plans do not necessitate ease of access to information relating to the care needs of the service users, which could place the service users at risk. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 10 The safety of a case tracked service user was further compromised, as the content of the care plans was contradictory. A care plan relating to pressure ulcer prevention stated that the service user should be encouraged to mobilise, whilst a care plan relating to mobility stated that the service user will require a Stand Aid to mobilise at all times. As far as practically possible, service users or their advocates should be involved in the care planning processes to ensure that informed consent is sought in relation to the content of the care plans. An examination of the case tracked care plans and a discussion with the acting manager confirmed that consent to the content of the care plans had not been sought. To ensure the safety of all service users within the home the registered person will ensure that service users care plans are re-evaluated and that the care plans are up to date and in address the holistic needs of all the service users. The registered person will also ensure that informed consent to the content of the care plans is obtained from the service users or their advocates whenever practically possible at the home. The inspector examined a random selection of service users Medication Administration Records (MAR). A service users MAR chart was hand written by the acting manager but the entries on the MAR charts had not been signed. To promote the service users safety at the home it is recommended that all hand writen entries on MAR charts are performed by a senior member of staff and checked and signed by another member of staff at the home to ensure the entries are correct. The inspector examined the medication fridge at the home. It was evidenced that the temperature within the medication fridge is monitored on a daily basis. The temperature had been recorded in degrees Fahrenheit and degrees Centigrade. This practice could cause confusion for the care staff at the home resulting in the medication fridge being ineffectively monitored. To minimise confusion it is recommended that the fridge temperature be recorded in degrees centigrade at all times and that the temperature within the medication fridge is maintained within the parameters of 2-8 degrees centigrade. Given the aformentioned issues the registered person will be required to evidence to the Commission for Social Care Inspection (CSCI) that staff at the Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 11 home, who are responsible for the administration of medicines have attended accredited training courses in relation to medication management to ensure the safety of service usrers is maintained. The relatives of two service users were spoken with on the day of the inspection to determine the degree of respect and dignity afforded to service users. The inspector received positive comments from the visitors, which included “ I am fully satisfied with the standards of care at the home”, “the staff are always welcoming to visitors”, “the residents are always well presented and well looked after” and “the home is like one big family”. The inspector witnessed staff addressing service users in a respectful manner, but also witnessed the inappropriate mobilisation of a service user to the toilet, which compromised the service users dignity. A member of staff used a commode rather that a wheelchair to mobilise a service user to the toilet. Furthermore the service user was taken to a small room adjacent to the toilet area next to the service users lounge and utilised the commode in that area. To ensure service users respect and dignity is maintained, the registered person will ensure that service users are mobilised in wheelchairs at all times. Furthermore the registered person will ensure that service users are provided with the opportunity to use the designated service users toilets in the home, or the toilets within their own private rooms. An examination of the staffing rota evidenced that the service users respect and choice had been further compromised. On two occasions in January 2007 an all male staffing compliment was on duty throughout the night period to provide personal care to the service users. To promote the service users respect, dignity and choice in relation to the provision of personal care the registered person will ensure that a mixed gender of staff is on duty at all times throughout the 24-hour period to perform personal care interventions. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. Standards 12, 13, 14 and 15 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. Service users are provided with social activities within the homes environment. Service users have opportunities to access the local community and to maintain their links with family and friends. Routines are flexible and service users are given choices in their lifestyles. Service users benefit from a varied appetising menu at the home. EVIDENCE: The acting manager stated that a designated Social Activities Coordinator (SAC) is not employed at the home. The acting manager and a member of staff spoken with stated that the care staff at the home provide service users with a varied social activities programme such as bingo, cards, dominoes and arts and crafts. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 13 The inspector discussed social activities with a visitor to the home. The visitor confirmed that she had witnessed several social activities being performed. She stated that she visits her relative on a regular basis, mostly in the afternoons, and has witnessed movement to music, sing songs and guest entertainers. The acting manager also provided evidence that a motivation class had been trialled on 19th Jan 2007; the event was well received by the service users and will be repeated on a monthly basis. Through conversations with visitors to the home and a member of staff the inspector confirmed that the home operates an open door policy in relation to service users family and friends visiting the home. Through conversations with the acting manager, service users and visitors to the home the inspector was able to determine that service users are encouraged to take control over their daily routine in the home. Service users and a visitor to the home stated that service users can retire to bed whenever they wish and that it is normal practice for some service users to watch televission until late at night if they choose. To determine the quality of meals at the home the inspector discussed the meal provision with the cook and examined the daily menus. On the first day of the inspection the service users lunch time menu comprised of chicken or minced beef and onion pie with a variety of vegetables followed by trifle, ice cream or fresh fruit. The tea time menu consisted of pork pie salad or baked beans and cheese on toast followed by lemon cake or fresh fruit. A visitor to the home also confirmed that the food is very good and that she had witnessed service users being offererd a choice in relation to meal provision. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is poor. Standards 16 and 18 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. The service users safety could be compromised as complaints and concerns are not documented effectively. Service users are placed at risk as it could not be evidenced that all staff at the home have received training in relation to the Protection of the Vulnerable Adult (POVA). EVIDENCE: The acting manager stated that all service users or their advocates are supplied with a service users guide which contains a copy of the complaints procedure. A visitor to the home confirmed that she had been given a copy of the service users guide and that it contained a copy to the complaints procedure. Visitors to the home stated that they felt confident that should they have any concerns relating to the care provision at the home they could discuss them with the acting manager and felt confident that she would deal with them effectively. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 15 The inspector examined the complaints book at the home and it was evident that the complaints book is not filled out effectively. The section for “actions taken following a complaint” was blank as was the section for “suggestions and comments”. The inspector also examined a “signing in book” on the second day of the inspection. It was evident that the book had not been utilized effectively as no entries were documented for 31/01/07 although the inspector had witnessed service users receiving guests to the home. Further examination of the signing in book evidenced that the book provides visitors with the opportunity to record comments and concerns they might have relating to the service provision at the home. The signing in book evidenced a recent entry relating to a service user falling in the lounge area at the home. The inspector examined an accident book, which evidenced that the fall had been recorded. On further examination of the accident book it was evident that eleven falls had been recorded in January 2007 some of which resulted in injuries to service users and one service user was hospitalised following a fall. The acting manager was spoken with in relation to the high incidence of falls at the home and she stated that on occasions service users are left unattended for short periods of time in the lounge area as a result of the current staffing levels. To ensure that service users safety is maintained the registered person will be required to demonstrate to CSCI the process for calculating the staffing levels staffing levels at the home to ensure the safety of service users is maintained. The registered person will also be require to provide details of the measures to be taken to prevent service users being placed at risk of harm as a result of ineffective service user supervision within the home. Rosewood House Care Home DS0000008796.V328547.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): Quality in this outcome area is good. Standards 19 and 26 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. The environment at Rosewood House is well maintained. The home is maintained to an appropriate standard of cleanliness. EVIDENCE: A partial inspection of the homes environment was performed, which included an examination of the case tracked service users bedrooms and the service users communal areas. All areas were found to be well maintained, clean and fresh. Service users bedrooms were well decorated, safe and fit for purpose. It was evident that service users had many personal possessions in their bedrooms Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 17 such as family pictures and ornaments, thus promoting a homely environment for the service users. At a previous inspection performed on 3rd May 2006 a requirement was set to ensure that mobility aids were not stored within the lounge area at the home as the practice resulted in a potential risk of falls for the service users. It was evident that the acting manger has addressed the identified concerns effectively as mobility equipment is no longer stored in the lounge area. Visitors to the home also confirmed that they were satisfied with the environment at the home and could not identify any areas of concern. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Standards 27, 28, 29 and 30 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. Service users needs are not fully met by the number and skill mix of staff. The service users safety is compromised, as the recruitment process utilised at the home is ineffective. It was not evidenced that staff at the home have received appropriate mandatory training to ensure the safety of service users at the home. EVIDENCE: As mentioned earlier in the report the acting manager stated that service users are not supervised at all times due to current staffing levels. A member of staff spoken with also confirmed that the current staffing levels results in service users being left unattended for short periods of time in the lounge area. Given that the home is registered for service users with dementia and the high incidence of recorded falls in January 2007 it is evident that service users supervision in the home is ineffective in ensuring their safety. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 19 To ensure the safety of service users the registered person will be required to provide evidence to the CSCI of how the staffing levels are calculated to address the needs of the service users, whilst taking into account the size, layout and purpose of the home. CSCI will consider taking regulatory action if compliance is not achieved. The Care Standards Act (2000) stipulates that the registered person will ensure that two written satisfactory references are obtained before appointing a member of staff. An examination of the last two members of staff to be employed at the home evidenced that the procedure had not been followed as a member of staff only had one written reference within their recruitment file. To ensure the safety of service users the registered person will be required to provide evidence to the Commission for Social Care Inspection, which clearly demonstrates the actions to be taken, to ensure that members of staff only commence employment following the required checks as stipulated in the Care Standards Act (2000). The Commission for Social Care Inspection will consider taking regulatory action if compliance is not achieved. The acting manager was asked to supply the inspector with evidence of the staff training provision at the home. The staff training records did not evidence that the acting manager promotes an effective staff training and development programme to ensure staff are competent in performing their roles at the home. To ensure the safety of service users the registered person will be required to provide evidence to the Commission for Social Care Inspection that staff are appropriately trained and competent in meeting the needs of the service users. CSCI will consider taking regulatory action if compliance is not achieved. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Poor Standards 31, 33 and 38 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. The heath and safety of service users at the home is compromised as the current management structure within the home ineffective. The home is not run in the best interests of the service users. The health, safety and welfare of service users is not fully promoted and protected. EVIDENCE: Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 21 Given the concerns highlighted throughout this report it is evident that the current management structure is ineffective in ensuring the health and safety of the service users at the home. At a previous inspection performed on 3rd May 2006 a recommendation was made that the registered person should appoint a suitably qualified manager and that the individual applies for registration with CSCI. The inspector was informed on the 3rd May 2006 that the acting manager was in the process of registering with CSCI and that the application would be forwarded to CSCI without delay. Through conversation with the acting manager on 31st January 2007 it was confirmed that she had not applied to be registered as the manager at the home and could not justify the delay in her application. The Care Standards Act (2000) states that any person who carries on or manages an establishment or agency of any description without being registered under Part II 11 (1) (as an establishment or, as the case may be, agency of that description) shall be guilty of an offence. To comply with the Care Standards Act (2000) the registered person will ensure that an application is received at CSCI and that an effective manager is registered. CSCI will consider taking regulatory action if compliance is not achieved. At a previous inspection concerns were identified in relation to the consultation process at the home. Service users or their relatives were not afforded the opportunity to express opinions and concerns within an open forum such as service user meetings. The acting manager was able to provide evidence that a service users meeting had been performed in May 2006 but the minutes of the meeting were not available for inspection. Visitors to the home stated that they have not attended any service users meetings and had not been provided with questionnaire relating to the care provision at the home. The acting manager was not able to evidence that effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The inspector examined documentation relating to routine maintenance in the home. The documentation was disorganised but it was evident that service Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 22 users are at risk as the documentation did not fully evidence that routine maintenance had not taken place. Portable Appliance Testing (PAT) was last performed on 18th August 2005, the nurse call system had not been serviced since the 4th January 2006, the emergency lighting system was last serviced 1st April 2004 and the acting manager was only monitoring hot water outlet checks sporadically. The registered person will be required to provide evidence to CSCI that the routine maintenance performed within the home is effective in promoting the service users safety at all times. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 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 2 17 x 18 1 3 x x x x x x 3 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x x x x 1 Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 24 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 Timescale for action The registered person will ensure 31/03/07 that care plans are effectively evaluated to identify the changing needs of the service users and that consent to the content of the care plan is obtained whenever practically possible. The registered person will ensure 31/03/07 that all staff at the home who are responsible for the receipt, storage, administration and disposal of medicines receive accredited training in relation to medication management. The registered person will ensure 14/03/07 that suitable arrangements are in place at the care home to promote the service users privacy and dignity and that service users are not mobilized on commodes and can access appropriate toilet facilities in the home. The registered person will ensure 14/03/07 that a mixed gender of staff is on duty at all times throughout the 24-hour period to perform personal care interventions. DS0000008796.V328547.R01.S.doc Version 5.2 Page 25 Requirement 2 OP9 13 3 OP10 12 4 OP10 12 Rosewood House Care Home 5 OP16 22 6 OP18 13 7 OP27 18 8 OP29 19 9 OP30 18 The registered person will ensure that the all element relating to complaints are effectively documented to include the actions taken following a complaint and suggestions and comments. The registered person will ensure that service users or not being placed at risk of harm as a result of ineffective service user supervision within the home. To ensure the safety of service users the registered person will be required to provide evidence to CSCI that staffing levels are calculated to address needs of the service users whilst taking into account the size, layout and purpose of the home. The registered person will ensure that newly appointed members of staff only commence employment at the home following the required Protection of Vulnerable Adult checks and Criminal Record Bureau checks, together with two written satisfactory references. The registered person will be required to provide evidence to CSCI of staff training provision which demonstrates that staff are appropriately trained and competent in meeting the needs of the service users Outstanding Requirement from 30/06/06 14/03/07 31/03/07 05/02/07 05/02/07 05/02/07 10 OP31 Schedule 2 11 OP33 24 The registered person will make 05/02/07 arrangements to appoint a suitably qualified manager in post and that the individual applies for registration with CSCI The registered person will ensure 31/03/07 that effective quality assurance and quality monitoring systems, DS0000008796.V328547.R01.S.doc Version 5.2 Page 26 Rosewood House Care Home based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. Outstanding Requirement from 30/06/06 12 OP37 17 The registered person shall 31/03/07 ensure that at all times records are available for inspection in the care home by a person authorised by the CSCI to enter and inspect the home. Outstanding Requirement from 30/06/06 13 OP38 13 The registered person will ensure 31/03/07 that unnecessary risks to the health or safety of service users are identified and that routine maintenance is effective in maintaining the service users safety. 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 OP9 Good Practice Recommendations It is recommended that the fridge temperature should be recorded in degrees centigrade at all times to minimise the risk of confusion. Rosewood House Care Home DS0000008796.V328547.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 House Care Home DS0000008796.V328547.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. 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