Inspection on 08/05/06 for Rosset Holt Home

This inspection was carried out on 8th May 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosset Holt Home 26/09/08

Rosset Holt Home 27/06/07

Rosset Holt Home 19/10/05

Rosset Holt Home 18/05/05

Rosset Holt Home 26/10/04

Rosset Holt Home 26/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Rosset Holt Home Pembury Road Tunbridge Wells Kent TN2 3RB Lead Inspector Gary Bartlett Key Unannounced Inspection 8th May 2006 09:30 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 Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rosset Holt Home Address Pembury Road Tunbridge Wells Kent TN2 3RB 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) 01892 526077 01892 526077 Keychange Charity Mrs Marilyn Rose Luck Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2005 Brief Description of the Service: Rosset Holt is a large detached property on two floors and stands in its own grounds. The Home is owned by the Keychange Charity and offers accommodation to older people with Christian beliefs. It is registered for 18 service users and all rooms are currently used for single occupancy although some are large enough to be used for shared occupancy if required. Six bedrooms have en-suite facilities. There are staff call points and television points in all bedrooms. The Home is equipped with a shaft-lift.Rosset Holt is located on the outskirts of Tunbridge Wells where there are the usual facilities of a town. There is access to public transport close by and the nearest Doctors surgery is a very short walk away. Space for car parking is available and there are spacious gardens for residents to use. The Home’s senior staffing team comprises the Manager and a Deputy Manager. The Home employs care staff that work a roster that gives 24-hour cover. The Home also employs other staff for catering, domestic and maintenance tasks. Current fees range from £400 to £450 per week Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Gary Bartlett, Inspector, who was in Rosset Holt from 9.30 a.m. until 5.15 pm. During that time the Inspector spoke with some residents, a visitor and some staff. Parts of the Home and some records were inspected. Some comment cards were received prior to the inspection. Residents and their relatives responded that they liked the home and staff. Responses from health professionals also indicated good standards of care. Statements on comment cards included: • “A very good, well organised residential home.” • “In my opinion the overall care I have observed at Rosset Holt has been excellent.” • “…is made to feel so cared for and happy in this home.” • “The home has a pleasant and happy atmosphere.” • “I feel lucky to be at Rosset Holt and cannot imagine anywhere better.” • “An excellent, caring, clean care home.” The Manager and staff gave their full co-operation throughout the inspection. What the service does well: What has improved since the last inspection? At last, some progress has been made to address most of the requirements notified in the previous inspection report, some of which had been in reports prior to that. The water and heating systems have been improved. The Home has sought specialist guidance to give residents with sensory impairment or physical disabilities the autonomy they want and, as far as is practicable, do not become isolated. Residents appreciated that an alternative hot main meal is now offered at lunchtime. The staffing ratio has been increased at Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 6 certain times and new staff are being recruited. There is more staff training being provided. Staff are being supervised regularly. Some parts of the Home have been redecorated. 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. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 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 Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 Quality in this outcome area was good. Good pre-admission assessments and the opportunity to visit the Home prior to admission ensured residents were appropriately placed and the Home could meet their needs. The Home did not provide intermediate care. EVIDENCE: The Manager said the Statement of Purpose was accurately descriptive of the aims, objectives, philosophy of care, services and facilities and terms and conditions of Rosset Holt. Although available, a copy of the Residents Guide had not been given to every resident or their representative, thereby denying them the information they might need about the Home. The Manager undertook to ensure residents were given a copy. The documents were not inspected on this occasion. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 9 The Manager described how a pre-admission assessment was made of each prospective resident using an aide-memoir. Records seen indicated prospective residents, their families, advocates, and relevant health care professionals were involved in the assessment process. Specialist advice was sought from external sources where required. Some residents said they or their families had been able to visit the Home before moving in and this had been very helpful in assisting them to settle in. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area was adequate. Residents’ health and welfare would be better promoted by better care planning and recording and by risk assessments being written when necessary. Residents were potentially at risk through the inconsistent completion of the Medication Administration Record sheets. Residents’ health needs were met with good liaison with relevant health care professionals. Staff treated residents with respect and maintained their privacy and dignity. EVIDENCE: Each resident had a care plan and four were inspected in detail. Although some work had been done to improve the care plans, they were still inadequate in regard to the detail of information in some parts. Care plans would benefit from including residents’ strengths and abilities in addition to their frailties. Daily records were not consistently detailed or informative, Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 11 although there were some very good examples. Care plans were being reviewed every three months rather than monthly as stated under the Standards. Risk assessments had not been reviewed or recorded as a result of some incidents. The scope and content of risk assessments still needed to be more comprehensive, especially considering that some residents regularly left the Home independently. It was important for necessary and current information to be recorded and readily available to staff for them to be able to meet residents’ needs. The Manager understood this and was aware that the care plans were not to the standard required. As discussed later in the report, the current staffing ratios and management involvement in some shift work meant there were limited resources available for the improvement and review of the care plans. Staff spoken with did, however, have a very good understanding of residents’ individual needs. The medicines storage room was inspected and medications were seen to be stored in accordance with their instructions. Refurbishment of the room was required to maintain hygiene standards. Records were available to indicate that all staff administering medications had been trained and signed off as being competent to do so. Some Medication Record Administration Record (MAR) sheets had not been completed appropriately. The Manager stated this would be investigated. Medications were seen being administered in compliance with current guidelines. The Home continued to have a good working relationship with the specialist and local health care professionals, supporting residents in their health care needs. A comment card received from a health care professional included the statement: • “When attention by a district nurse is required eg change of dressings, the senior member of staff on duty at the time has always actioned this request promptly.” From observation and discussion with residents it was clear that staff treated residents with respect and promoted their privacy and dignity. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area was adequate. Residents had some choices about their daily lives, were able to have visitors at any reasonable time and enjoyed continued links with the local community where this was their preference. Residents enjoyed the food and had a choice of meals. EVIDENCE: Bible studies and prayer meetings were held daily and the Manager confirmed that service users chose whether to attend the services or not. A notice board in the entrance hall was seen to include details of forthcoming activities that the Home had arranged. There was not agreement as to whether enough activities were provided. Some residents were very happy with what was on offer, others would have liked more. As mentioned later in this report, this could be resolved through more formal consultation with the residents. Statements on comment cards received included: • “My only disappointment with the home is the lack of activity and entertainment.” • “Only one afternoon outing for afternoon tea has been arranged since Christmas.” Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 13 Since the last inspection, the Home had sought advice from appropriate specialists about providing care for individual residents with sensory impairment or physical disabilities. The Manager stated that their recommendations had been implemented. Residents said that they were able to receive visitors at any reasonable time and could receive their visitors in a comfortable room in private should they choose not to use their bedrooms. Some residents occasionally stayed with friends and family for weekends etc. A visitor said they were always made very welcome at the Home. Residents said they enjoyed the meals and had plenty to eat. They appreciated that an alternative hot main meal was now offered at lunchtime. The meals were well presented and looked appealing. Lunch was taken in a relaxed atmosphere and staff were seen to be helpful where required. Statements on comment cards received included: • “Food is excellent and suitable for my needs.” • “On the whole I think the food is excellent.” Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area was good. Residents and their relatives knew their complaints would be listened to and acted on. There were systems to ensure residents were protected from abuse. EVIDENCE: A statement on a comment card received included: • “I seldom need to complain. Everything runs smoothly.” Residents benefited from the complaints procedure being readily available. Some residents and a visitor described how they knew of the complaints procedure but had not had reason to use it. They said the Manager or Assistant Manager were usually available to “sort things out”. The Manager stated records of complaints would be kept and these include details of investigation and action taken and would be used to inform future practice. There had not been any complaints since the last inspection. There were procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The Manager and a staff member spoken with had a sound understanding of adult protection procedures. The Manager stated that any allegation of abuse would be referred to the concerned agencies without delay. This had not been a necessary to Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 15 date. The Manager was aware that the staff mandatory training schedule required POVA training to be added. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26 Quality in this outcome area was adequate. The standard of the environment within the Home was generally good providing residents with an attractive and homely place to live. Parts of the Home do not promote infection control and ensure the residents’ health and safety. EVIDENCE: The parts of the Home inspected were clean and free from unpleasant odours. Residents said they had access to all parts of the Home and facilities they needed. They were happy with their bedrooms and found the communal areas comfortable. The bedrooms seen had been personalised with the occupants’ personal effects and reflected their individual tastes and interests. There was an ongoing programme of redecoration and refurbishment. Some parts needed it; trip hazards were caused by some carpet on the first floor Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 17 landing that was loose, a loose separator on the ground floor and by an uneven external pathway outside a fire escape. Improvements were needed to the medicines room to better promote infection control. To this end, worn commode frames need to be replaced. Residents and staff said that bathing and toilet facilities were adequate. Although fitted with thermostatic control valves, the hot water supply at some baths was higher than 43 degrees C. This placed residents at potential risk, as did the radiators running with very high surface temperatures. The Manager explained that the budget for the recent improvements to the water and heating systems had included the covering of the radiators, but for reasons unknown this had not been done. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area was adequate. Recruitment processes are robust and offer protection to people living at the Home. Staff are not yet fully trained to meet the needs of the residents. EVIDENCE: Residents spoke highly of staff and thought they worked hard. Statements on comment cards received included: • “The staff are very kind and do what they have time for.” • “The staff are friendly, kind and considerate.” • “I have always found all those on the staff with whom I have come into contact extremely helpful.” The Home continued to have a consistant staff group that had been augmented by a new staff member since the last inspection and another was due to start in the near future. There was again some discussion about the need to discourage complacancy and resistance to change amongst a staff group that had been in place for a long time. The staffing ratio had been increased at certain times and the Manager stated they considered staffing levels adequate. During the inspection, it was seen that the Manager and Assistant Manager were frequently diverted to receive Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 19 telephone calls and visitors. The Manager mentioned that administrative support was not available to them. This would particularly impact at such times as the Manager was on duty as part of the rostered staff. The staff roster was inspected and showed that one staff member was working 4 consecutive night shifts followed by 6 consecutive nights after only one night off. The Manager explained this was unusual and was to cover for holidays but did acknowledge that long consecutive shift patterns could compromise staff competency through fatigue and thereby put residents at risk. Staff recruitment processes were robust enough to ensure only properly vetted people worked at the Home. The Manager stated they were intending to write a revised training matrix for easy monitoring of staff’ training/update requirements. There had been recent progress in arranging training for staff but further training courses were still required. The Manager described how NVQ training had been arranged. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area was adequate. The Home does not have robust and proactive management systems. Residents are potentially at risk through poor environmental checks and lack of staff fire-training. EVIDENCE: Statements on comment cards received included: • “Matron who is very sympathetic and understanding.” • “Rosset Holt is extremely well managed by Marilyn and Dianne. I have no concerns about their care of residents at all.” Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 21 Throughout the inspection, the Manager demonstrated a desire to provide a high quality service. Staff and residents said they considered the Manager to be very approachable. The Manager had completed the Registered Manager’s Award As mentioned previously in the report, the Manager’s involvement in some shift work meant there were limited resources available for the improvement and review of the care plans and management systems, e.g. more robust checks of the environment. The Manager acknowledged this had contributed to the failure to address some requirements in the last inspection report. A system of regular staff supervision had been implemented and was being conducted by the Assistant Manager who had undertaken supervision training. A residents’ meeting had not been held since August 2005. The advantages of holding residents’ meetings more frequently, improving the questionnaire and of holding relatives’ forums, were again discussed. Residents’ did not express any concerns about the Home’s management of monies or valuables held on the their behalf. The Home encouraged residents to manage their own financial affairs or to have assistance from their families / representatives. There was an adequate system of holding and recording residents’ cash, which facilitated ease of monitoring. The Manager said these were regularly audited. Staff were seen to be diligent in minimising risks to residents by carefully placing equipment to avoid obstruction and in ensuring COSHH requirements were adhered to. Although staff spoken with knew what to do in the event of a fire, records showed that not all staff have undertaken fire drills/training at the required frequency. The accident records seen had been completed appropriatly but one had not been transposed to the residents’ daily records of care. Consequently, the incident could be unknown to care staff who referred to daily records and not individual accident reports. It was recommended a system of monitoring accidents for frequencies, trends and patterns be introduced. The Manager stated that records of maintenance and safety checks were up to date. These were not inspected on this occasion nor were the Home’s policies and procedures. Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 22 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 2 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 3 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 3 2 1 Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 5(2) Requirement “The registered person shall supply a copy of the service user’s guide to the Commission and each service user.” This must be done by the given timescale. “The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review” in that service users’ individual plans and records must be kept and be up to date in that they must be consistent and specific in detail of information. The given timescale of 30/01/06 had not been met. Improved care plans must be in place by the given timescale, if not sooner, and thereafter maintained The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be more comprehensive and recorded in DS0000023998.V292909.R01.S.doc Timescale for action 30/06/06 2 OP7 14(2)(b), 15(2), 17 Schedule 3, Schedule 4 31/07/06 3 OP9 13(4) 31/07/06 Rosset Holt Home Version 5.1 Page 24 3 OP9 12(1)(a), 13, 17(1), Schedule 3 4 OP19 13(4) 5 OP26 13(3) response to incidents and changes in residents welfare. The given timescale of 30/01/06 had not been met. Comprehensive risk assessments must be in place by the given timescale, if not sooner, and thereafter maintained. “The registered person shall 16/06/06 make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that M.A.R. sheets must be completed accurately and anomolies investigated and resolved without delay. An action plan must be received by CSCI by the given timescale. 16/06/06 “The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety” in that: 1. All damaged carpets must be made good or replaced. 2. The uneven external pathway must be made good. 3. Hot water at baths must be provided at a safe temperature to prevent scalding. 4. Radiators and pipework must be guarded or have guarunteed low temperature surfaces. An action plan must be received by CSCI by the given timescale. “The registered person shall 16/06/06 make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home”, in that: 1.The walls and floor covering of the medicines room must be made good. DS0000023998.V292909.R01.S.doc Version 5.1 Page 25 Rosset Holt Home 6 OP30 18 2. Worn commode frames must be replaced. An action plan must be received by CSCI by the given timescale. “The registered person shall having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they perform including structured induction training An action plan must be received by CSCI by the given timescale. 16/06/06 7 OP33 12(3) 16(2) 8 OP37 17(2) 19 9 OP38 23(4)(e) 16/06/06 “The registered person shall, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings” in that there must be better quality assurance systems. For example, more regular residents meetings. An action plan must be received by CSCI by the given timescale. Staff records must comply with 04/08/06 Schedules 2 and 4. The given timescale of 30/11/05 had not been met. Failure to comply by the given timescale, if not sooner, may result in enforcement action. “The registered person shall 30/06/06 ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life” in that fire DS0000023998.V292909.R01.S.doc Version 5.1 Page 26 Rosset Holt Home training must be provided at regular intervals. This refers to all staff, including night staff. The given timescale of 30/11/05 had not been met. Failure to comply by the given timescale, if not sooner, may result in enforcement action. 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 Refer to Standard OP7 OP18 OP27 Good Practice Recommendations It is recommended care plans are reviewed by care staff in the home at least once a month. It is strongly recommended the Manager proceeds with the stated aim of adding POVA to the staff mandatory training schedule. It is strongly recommended the Manager works less rostered staff hours and additional administrative/reception support be provided to allow them more time to meet their responsibilities. It is strongly recommended staff do not work long consecutive shift patterns that may compromise their competency through fatigue. It is recommended that 50 of care staff in the home hold an NVQ qualification of level 2 or above. It is recommended the Manager completes and maintains the proposed training matrix. It is recommended environmental risk assessments be undertaken more frequently and that staff be trained in this. It is recommended a system of monitoring accidents for trends and patterns be introduced. 4 5 6 7 8 OP27 OP28 OP30 OP38 OP38 Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rosset Holt Home DS0000023998.V292909.R01.S.doc Version 5.1 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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