Inspection on 01/10/08 for Rosglen

This inspection was carried out on 1st October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosglen 30/09/09

Rosglen 03/10/07

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

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 13/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Rosglen 2 Highfield Range Darfield Barnsley South Yorkshire S73 9BQ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jayne White     Date: 1 6 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Rosglen 2 Highfield Range Darfield Barnsley South Yorkshire S73 9BQ 01226752238 01226752238 none Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Just Global Limited Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 11 Number of places (if applicable): Under 65 Over 65 9 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who can be accommodated is: 11 The registered person may provide the following category of service only: Care Home only - Code PC To Service users of the following gender - Either Whose primary care on admission to the srevice are withing the following cateogires: Old age not falling within any other category - Code OP, maximum number of places, 11 Date of last inspection Brief description of the care home Rosglen is a care home providing personal care and accommodation for 11 older people. Just Global Limited bought the home in May 2007. The home is situated in Darfield, Barnsley. It is close to a bus route and there are shops, including grocers, hairdressers, chemist, post office and newsagents in the village. The home is single storey. It has 7 single and 2 double rooms. Communal areas include two lounge areas and a dining room. There is a central kitchen and laundry. There are some bathing Care Homes for Older People Page 4 of 30 Brief description of the care home facilities. Information about the home, including the service user guide is available in the entrance hall. This includes the most current CSCI report about the service. The owner said the fee range was 351.50 - 381.50. The service user guide states additional charges are limited to personal extras including toiletries, hairdressing, private medical treatment, chiropody, dentistry, optical services etc, dry cleaning, telephone calls and non-urgent escort services. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was a key inspection and comprised information already received from or about the home and two site visits. We visited the home on 1 October 2008 between the hours of 8:45 and 15:30 without giving them any notice. We completed the visit on 16 October 2008 between the hours of 14:00 and 16:00, when we told the service we would be visiting. Various aspects of the service were checked during the visit. Care practices were observed, a sample of records were looked at and the service provision was discussed with the owner and manager. All people living at the home were seen throughout the visits and five of these were Care Homes for Older People Page 6 of 30 spoken to in more detail about the care they received. The care provided for three people was checked against their records to determine if their individual needs identified in the plan of care were being met. We also spoke to two members of staff about the care they provided to people and their recruitment, induction and training. A health professional was also spoken with. All this information and peoples, staff and health professionals opinions and comments were considered for inclusion in this report. The inspector wishes to thank people living at the home, the staff, the owner and manager for their assistance and co-operation during the visit. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? Staff knew the procedure to be followed when tablets were dropped on the floor, which meant people would get all their prescribed medication and appropriate records would be maintained. Records of concerns people had were being recorded, investigated and action taken to prevent a reoccurence, demonstrating their complaints were being taken seriously. A cook was employed between the hours of 10:00 and 14:00. This meant care staff could concentrate on caring duties. There had been changes in the way people chose their meals. The cook to people individually and offered choices to them. When we spoke to people about the meals that were now served they said, theyre very good and you get plenty, Jazz (the owner) is very good about meals - weve got better quality meat and shes bought prawns and you dont have to have it if you dont like it. The variation of registration had resulted in improvements to peoples living environment. These included redecoration and refurbishment of the hallway, lounges, dining room, bathroom and shower room. So that people were safeguarded staff hadnt commenced work until all recruitment Care Homes for Older People Page 8 of 30 checks had been completed. Servicing and maintenance of all equipment was up to date. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People received information they needed to choose a home and had their needs assessed before they moved in. This meant both the home and the person could be sure their needs would be met. Evidence: We looked at the files for three people. They contained an assessment from the placing care manager and an assessment from the homes manager. Overall, a good plan of care had been put together from the information. When we spoke to people they told us theyd received enough information before they moved in. One person said, my daughter looked at 17 places before choosing this. The service user guide included a statement of terms and conditions/contract. The owner was told the guide needed to include the range of fees, so that people have a Care Homes for Older People Page 11 of 30 Evidence: clear understanding of what the charges might be. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people received reflected what assistance they needed. People were treated with respect, dignity and privacy. Evidence: On the whole, when we spoke to people they were happy with the way that most staff looked after them and respected their dignity. They said, couldnt be better looked after - theyre lovely all of them. There isnt a bad one (staff) among them and if they (homes) were all like this, there wouldnt be any problems. When we observed staff working there was a clear and respectful communication between people and staff and staff treated people in a kind manner. Staff included people in conversation and day-to-day life. We looked at three care plans. The plans contained good information. There was sufficient detail on the plan for staff to be clear about the care to be provided. This enabled carers to have clear information about what they needed to do to meet a Care Homes for Older People Page 13 of 30 Evidence: persons health and personal care needs. The daily report confirmed they followed this plan. Risk assessments were in place, however, when we saw staff move people it didnt reflect the information in one of the assessments we looked at. In addition, the assessment hadnt included the reason why the moving and handling arrangements had changed from when the person moved from their previous place of residence. The owner was told about this and was asked to arrange for a review of the assessment. Also, we saw staff moving people by holding them up under their arms, because the person they were moving was unable to weight bear. This is poor practice and not an accepted way of moving people. At the second visit, the owner confirmed shed asked staff about moving people in this way and the member of staff whod received training in moving and handling had said she knew she shouldnt. A warning letter has been sent to the provider to inform them enforcement action may be taken if they continue to fail to comply with taking action to meet previous requirements about moving people safely. People had access to health care services. Where people were unable to access local services they were supported by visits to the home by health care professionals. There was evidence in the care plan of health care treatment and intervention and a record of general health care information. When we spoke to a health professional they said they had no concerns about the way the service cared for people. They said, its nice here. Id put my mum in here, staff care, theyre bothered and know the residents, theres no issues with pressure area care or any other health care interventions and the service seek advice when needed and act on any advice you give. We looked at how the service stored medication for people. The majority of medication in the medication room was stored in accordance with current safe custody regulations, but we found an open container of medication on the floor. On the second visit, the owner had addressed this by fitting a further cupboard to store medication safely. When we looked at medication records there had been errors made in recording the use of controlled drugs. The recommended process for recording the receipt of controlled drugs was not being followed, which increased the risk of loss or diversion of this group of medicines. The owner and the person in charge on the day of inspection were told to rectify this. We observed staff giving medication to people. Good techniques and practices were used. Medication was givien to people on individual trays, in individual medication pots Care Homes for Older People Page 14 of 30 Evidence: with a drink of water. Staff gave people sufficient time to take their medication, helping them to do this where necessary. This resulted in people taking their medicines when asked to do so. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were assisted to make choices and decisions in their daily life. Social activities did not always meet peoples expectations. Evidence: When we entered the home there was a pleasant ambience in the lounges. People that were up were sat in the lounges either asleep or displaying withdrawn behaviour, that is, being awake, but in their own inner world. The TV was on in one lounge, but no-one was watching it. In another lounge, a local radio station was on as background noise, but again no-one was listening to it. During the visit we asked people about the opportunities they had for taking part in social activities. They said, we watch TV, there used to be dominoes or cards, but theres only two of us now thats interested, so its not worth it, it doesnt bother me, not doing anything, they dont do anything and weve not been out for a meal since Christmas. There were some people whom we spoke to who preferred spending time in their room. They said they liked to keep themselves busy and alert by reading, doing crosswords, listening to radio and watching TV. Care Homes for Older People Page 16 of 30 Evidence: When we looked at the admission assessments of three people, they provided some information of what activities and hobbies they might like to take part in. When we looked at the care plans, they did not include how people had been consulted about what activities might be carried out with them to engage them in meaningful daytime activities of their own choice, interest and capabilities to enhance their well-being. However, there was an activities and social record. In all three of the records, there was no record of any specific activity the person had taken part in that had been initiated by the service. The record identified visits from friends and family as the only activity specific to the persons own individual leisure and social interests and pursuits. When we spoke to people they confirmed they had visits from their family. In contrast, people were mainly positive about their lifestyle within the home. They said, its nice here. You can please yourself what you do, its home, theres no pressure about when to get up and go to bed and you can have a shower when you like, but I like it twice a week. When we spoke to the owner she said she was considering appointing someone to carry out social activities with people because she was aware this was an area that could improve. There had been changes in the way people chose their meals. The cook spoke to people individually and offered choices to them. This resulted while we were there of two meals being served at lunch time. When we spoke to people about the meals that were served they said, theyre very good and you get plenty, Jazz (the owner) is very good about meals - weve got better quality meat and shes bought prawns and you dont have to have it if you dont like it. We saw breakfast and lunch being served. The meals were well presented and the meal time was a leisurely and relaxed time for people. Staff were patient and helpful and allowed people time to finish their meal comfortably. Breakfast was a variety of cereals and toast and this was served to people as they got up. There were some people able to pour themselves a drink and butter their toast, but staff did this for them. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to express their concerns and had access to a complaints procedure. There were adult safeguarding policies and procedures in place that promoted the protection of people from harm. Evidence: On the whole, when we spoke with people they said they were highly satisfied with the care they received and felt safe. They said they would speak up if there was something they werent happy about. This indicated there was an open culture that allowed people to express their views and concerns in a safe and understanding environment. The majority said they had no complaints or grumbles. People felt the owner listened when they did have anything to say. People could access the complaints procedure because it was displayed on the notice board in the entrance hall for them should they wish to make a complaint. It was clearly written, easy to understand and explained what the procedure was and how long the process would take. We looked at the complaints record and this included details of the investigation and any actions taken. A concern had been raised directly to the Commission about the amount of food Care Homes for Older People Page 18 of 30 Evidence: served to people. The information was provided to the owner to respond to the concern, which she did. It was about the amount of food being served to people. This was not recorded in the complaints record and should be. This was highlighted to the owner. Complaints made directly to the service were recorded in the record, how it had been investigated, an outcome and any action that had been taken to rectify the complaint if necessary. There were adult safeguarding policies and procedures in place that promoted the protection of people from harm or abuse. They were available to staff and gave clear, specific guidance to those using them. There had been no referrals to adult safeguarding. When we spoke with the owner about adult safeguarding they were unclear of the procedure to be followed should an allegation of abuse be made. She acknowledged her lack of knowledge and agreed she needed further training. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. On the whole, the design and layout of the home enabled people to live in a clean, well maintained, safe and comfortable environment. Evidence: A variation of registration had been agreed to increase the numbers living in the home to a maximum of eleven. There had also been changes to the living environment. The dining room was now situated in the conservatory and what was the dining room was now another lounge. There had been redecoration and refurbishment of the hallway, lounges, dining room, bathroom and shower room. This had resulted in living areas being much brighter. People said the owner had consulted with them about some of the refurbishment purchases. The owner was aware of other improvements that would make the environment better for people. In addition, that she still needed to fit intermittent strips ot the fire doors as recommended by the Commission registration team when they approved the variation. She said this would be done in the next month. The variation meant there was now a selection of communal areas, which meant people had a choice of where to sit, meet with family, sit quietly or engage with other people that lived there. It also provided sufficient space for the number of people that lived there. Access around the home was good. Care Homes for Older People Page 20 of 30 Evidence: On the whole, when we spoke to people they said they thought their home was comfortable, but they did say the new chairs in the dining room could have been more comfortable. Also, we saw that people who experienced difficulty sitting upright slid down in the chairs. We told the owner about these concerns. People said they had a comfortable bedroom, which they had personalised with pieces of their own furniture and possessions. Improvements to the home had meant that some people now had en-suite facilities. We also told the owner that the air temperature in the dining room was cool in the morning and the radiator itself was cool indicating it had been on, but had gone off and was therefore on a timer. However, in the afternoon the radiator was very hot, which presented a risk of people burning themselves on it. When we spoke to the owner she was told about this. She confirmed the heating was on a timer, but people hadnt complained it was cold. This was different than what people had said to us. However, the complaints record in one instance identified there could be explanations for this. She was asked to monitor this, so that the temperature was satisfactory for all people. When we looked round the home it was well lit and smelt fesh. There were some areas that were dusty and untidy. The owner was told about this (see staffing section). There were sufficient toilets for people that were appropriately located and easily accessible. We brought to the owners attention, that a nail brush left on a sink for people to use was not good practice in preventing the spread of infection. This was removed. Also, that it was good practice to provide paper towels in toilet areas. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was an experienced and stable staff team, which contributed to the smooth running of the service, but having specific ancillary staff would increase the time staff have to spend with people, improving their quality of life. Evidence: Generally, when we spoke to people they had confidence in the staff that cared for them and that on the whole staff were usually available when they needed them. Their specific comments included, we couldnt be better looked after. Theyre lovely all of them (staff). There isnt a bad one amongst them, if they (homes) were all like this, there wouldnt be any problems and the staff are marvellous. We observed how staff worked during the visit. This told us there were good relationships between staff and people and they responded in a timely way when people needed assistance. Staff were bery busy helping people with their physical care needs. A number needed a lot of help and required the assistance of two people when being assisted to move or transfer. In addition, care staff carried out the cleaning duties. This meant that other then when assisting people at this time or when providing assistance at meal times, they spent little time with them pursuing their leisure and social interests. Care Homes for Older People Page 22 of 30 Evidence: When we spoke to the owner they said there was always two members of care staff on duty. During the day, a cook worked 10:00 - 14:00. This meant care staff also made breakfast, tea and supper meals. This was confirmed when we spoke to people that lived there and looked at the rotas. We discussed with the owner about having ancillary staff, because of the lack of individual social pastimes that people could take part in and also that some areas of the home were found untidy and dusty. She stated she wasnt looking at domestic staff as she felt staff had time to do this, but was considering having an activities person. The service had a recruitment procedure that included prospective employees completing an application form, the service obtaining two written references, documentation of a full employment history and a Criminal Records Bureau and Protection Of Vulnerable Adults first check. Training opportunities were provided. These included, induction, first aid, health and hygiene, moving and handling, health and safety, NVQ Awards, fire safety, medicine, adult safeguarding and dementia. When we looked at the training matrix, however, it identified the majority of staff needed refresher training in first aid and fire safety. First Aid training had been arranged, but there was no plan for fire safety (se management and administration). At the previous inspection, a requirements had been made with a timescale of 30 April 2008 for staff to receive infection control training. Staff had not received this training, but it had been planned. However, this does indicate a lack of importance attached to meeting requirements by the owner and manager. The owner and manager were told, not keeping up to date with training could place people at risk and meant staff were could not be up to date with current good practices to keep people safe. How staff moved people, nail brushes being left in sink areas and not providing paper towels in toilet areas were given as examples (see health and personal care and environment). The manager told us the first aid training on the training matrix was emergency aid. At the previous inspection we had recommended a risk assessment was put in place to determine this was satisfactory to keep people and staff safe in the event of an accident or medical emergency. It hadnt been completed. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home was based on openess and respect. Generally, the administration showed there were sytems in place to manage the health, safety and welfare of people and staff, but these were not always satisfactory. Evidence: Overall, people were pleased with the service and spoke highly of the owner. They said, one thing shes been good about is food, its much better quality, shes approachable, listens, is on call and is a noce person and the time she spends here is getting less. The manager had many years experience within the caring profession. She had achieved the Registered Managers Award. She had a good knowledge of the needs of people and she was committed to providing a good quality service. There was a relaxed atmosphere within the home. However, the manager needed to ensure the systems in place to monitor staffs adherence to policies and procedures during their Care Homes for Older People Page 24 of 30 Evidence: practice was effective. For example, moving and handling, medication and infection control measures (see health and personal care and environment). In addition, the manager needs to ensure risk assessment reflect how people are to be moved safely (see health and personal care). On the first day of the visit, the owner was present but was unable to access some information that was required for us to be satisfied that regulations and National Minimum Standards were being met. This included the last quality assurance survey, recruitment and training files, servicing and maintenance records and a copy of their reports of their findings of the quality of the service provided, in their unannounced monthly visits to the home. This resulted in a further announced visit. The owner must consider how this is to be achieved in future when the manager is not available. At the further announced visit, we identified quality assurance systems were in place, but these needed more co-ordination, to produce a plan of action about what the service intended to do to improve the quality of the service after consultation with people. We talked about this with the owner and manager. We also looked at a sample of maintenance and service records. These were up to date and current to the services provided. The fire risk assessment had been reviewed on 28 August 2008. It was brought to the owners attention that the inclusion of the roll call was good practice, but it was out of date and needed amending. This is important, as the home and the emergency services need up to date information so they take appropriate action in an emergency. Also, it was highlighted to the owner and manager they could be placing people and staff at risk of harm because the training matrix for fire safety identified training needed updating and a date had not been planned. The owner said that the service now didnt deal with any monies on behalf of people. Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 38 13 (4) (c) This also relates to the outcome for standard 28, qualifications and standard 30, staff training. People must be moved safely, including not holding people up under their arms. Previous timescale of 03.10.07 not met. 03/01/2009 Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 This relates to Regulation 13 18/01/2009 (4) (c) It is also applicable to the outcomes for standard 28, qualifications, standard 30, staff training, standard 31, day to day operations and standard 38, safe working practices Moving and handling risk assessments must be up to date, take into account previous moving and handling assessments and involve appropriate professionals. So that people are moved safely. 2 19 13 Regulation 13 (4) (a) & (c) 18/01/2009 This also links to the outcome for standard 38, safe working practices. A risk assessment must be conducted on the risks presented by radiators that are not protected by guards. In addition, that any action Care Homes for Older People Page 27 of 30 identifed to reduce the risks are acted on. So that people as far as reasonably practicable are free from hazards to their safety. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 This is also applicable to the outcome for standard 31, day to day operations. When medication is received that is identified as controlled medication, it should be recorded in the controlled drugs register, so that the risk of loss or diversion of this group of medicines is reduced. This is also applicable to the outcome for standard 31, day to day operations. All medication should be safely stored in medication storage that complies with current safe custody regulations. Consult with people about what activities might be carried out with them to engage them in meaningful daytime activities of their own choice, interest and capabilities to enhance their well-being and include these in their plan of care. This also links to the outcomes for standard 38, safe working practices. Improve systems for monitoring the control of infection by providing paper towels in toilet areas. Consider employing ancillary staff, so that care staff have more time to involve people in their chosen individual social pastimes. This also links to the outcomes for standards 30, staff training, standard 31, day to day operations and standard 38, safe working pratices. Training in fire safety should be updated, so that staff are up to date with the procedures to be followed in the event of a fire, so people are kept safe. This also links to the outcomes for standard 30, staff 2 9 3 12 4 26 5 27 6 28 7 28 Care Homes for Older People Page 28 of 30 training, standard 31, day to day operations and standard 38, safe working practices. Complete a risk assessment that identifies what training is sufficient for staff to safeguard people and staff when there is an accident or medical emergency. 8 38 To keep people, staff and other professionals safe, the fire roll call should be kept up to date at all times. Care Homes for Older People Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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