Inspection on 13/12/06 for Rowan Court Nursing & Residential Home

This inspection was carried out on 13th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Rowan Court Nursing &... 14/02/06

Rowan Court Nursing &... 26/07/05

Rowan Court Nursing &... 08/03/05

Rowan Court Nursing &... 27/09/04

Rowan Court Nursing &... 12/02/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Rowan Court Nursing & Residential Home Silverdale Road Newcastle Staffordshire ST5 2TA Lead Inspector Mrs Yvonne Allen 2nd inspector Mrs Jane Capron Key Unannounced Inspection 13 December 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 Rowan Court Nursing & Residential Home DS0000026963.V323734.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. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowan Court Nursing & Residential Home Address Silverdale Road Newcastle Staffordshire ST5 2TA 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) 01782 622144 01782 625301 rowancourt@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Limited Mrs Rachel Lisa Simpson Mrs Alison Margaret Brown Care Home 76 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (19), Old age, of places not falling within any other category (76), Physical disability (42), Physical disability over 65 years of age (76) Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 42 PD aged 60 years and over Date of last inspection 14 February 2006 Brief Description of the Service: Rowan Court is a care home providing personal care including nursing care for up to 76 elderly service users. This includes personal care of service users with a mental disorder over 65 years of age and care of elderly service users who have physical disabilities. A company owns the home - Southern Cross Healthcare Services Limited. The home is located within walking distance to the Staffordshire town of Newcastle-Under-Lyme with its array of amenities. The home is relatively new having been purpose built in recent years and consists of two floors served by a passenger lift. There is ample car-parking facility at the entrance car park. Gardens are accessible around the home to service users including wheelchair users. The accommodation provides for single bedrooms, all of which have en-suite facilities. There is ample provision of communal and seating areas throughout the home. There are three units within the home. On the ground floor there are two units - one that accommodates service users needing personal care and the other accommodating service users with personal care including mental health care needs. The second floor accommodates service users requiring nursing care. All units are staffed and managed separately. The fees charged range from £325.00 to £659.00 with extra charges payable for private chiropody, toiletries, trips out, newspapers and taxi fares. The home accommodates self-funding residents and individuals funded by social services and the health authority. This information was provided by the Registered Managers via the Pre Inspection Questionnaire, which was received on 01/12/06. A full breakdown and explanation of fees can be obtained by telephoning the home and speaking to one of the two Registered Managers. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection visit was carried out by two inspectors and took 5 hours to complete. Some information had been requested and provided via the Pre Inspection Questionnaire. Comment cards had been sent out to residents, relatives, placement officers and GPs. Completed cards had been returned from 4 relatives, 2 placement officers and a GP. No comment cards had been received from residents prior to the visit but individual thoughts and comments about the home were obtained during the visit and have been included in the main body of this report. All the key standards were assessed during this visit and evidence was gained via the following methods – Direct observation of care practices Tour of the home including all communal areas and a sample of bedrooms Discussions with residents Discussions with visitors Discussions with staff Discussions with one of the Registered Managers Examination of relevant records and documentation The one requirement made at the last inspection had been addressed. There were 2 immediate requirements and 3 other requirements made during this inspection What the service does well: Most of the key standards were fully met and some were exceeded. The assessment and meeting of individual and collective needs was very good. The standard of care planning was high with evidence of good multidisciplinary interaction. There were records of visits by GPs, Chiropodists, Opticians, Dieticians, Dentists and Psychiatrists. Evaluations of plans had taken place on a regular basis and there was evidence of good communication with and participation by relatives. Individual personal, nursing and healthcare needs are met by a skilled and competent workforce and staff are trained and equipped to carry out their jobs. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 6 Staff are professional in their approach and demonstrated a good rapport with the residents and with each other. Privacy and dignity are promoted at the home and there was an example of where diverse needs are recognised and met by the staff. The staff recruitment procedure is robust and helps protect residents from harm or abuse. Autonomy is promoted and residents have a voice and can make choices about the lifestyle they lead in the home. Although the home has routines, these are flexible and varied and suited to individual needs and wishes. There is a good programme of activities in the home and individuals are assessed as to their wishes and abilities. Individuals are encouraged to maintain their hobbies wherever possible. Individuals are made to feel valued and respected. The home is very well managed by the two Registered Managers and the managers of each unit. This arrangement seems to work very well and there is always access to a senior manager for residents, relatives and staff. The home is run in the best interests of the residents who live there. Quality auditing is good and the home constantly thrives to evaluate and improve the services it offers. What has improved since the last inspection? What they could do better: The boilers, which served the central heating system and the hot water supply, were not working to full capacity at the time of the inspection and there were areas of the home, which were not adequately heated. Also records of hot water temperature testing indicated that temperatures were inconsistent. Two immediate requirements were left at the time of the inspection visit and the home has confirmed, in writing, that these have now been addressed. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 7 The general cleanliness of the home was good. However, the laundry was in need of a thorough tidy and clean and the dust behind the driers needs removing on a regular basis to comply with fire safety regulations. Although fire safety checks are carried out and recorded, there were some gaps in this when the maintenance person had been on annual leave. Arrangements will need to be made to continue recording these in his absence. The standard of meals served at the home was generally good but feelings about the food were mixed. One of the dishes served was at the time of the inspection visit was not what it should have been and menus and meals require reviewing with the views of the residents being taken into account. Although all concerns and complaints are dealt with effectively the recording of outcomes requires tightening up. 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. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 4 were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families can be assured that the home they are entering will meet their assessed needs. EVIDENCE: Discussions with residents and staff and examination of records identified that individual needs are assessed prior to admission to the home. These assessments were seen contained in individual care plans. Some of the residents spoken to confirmed that “someone from the home” had been to see them before they were admitted. The manager on duty confirmed that pre-admission assessments were carried out by herself, the other manager, or one of the unit managers. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 10 The manager on the residential care unit confirmed that she feels more confident now in carrying out these assessments. Documentation was also seen to confirm that individuals who came into the home funded by social services had undergone a separate assessment of their needs by their social worker. Evidence contained in other outcome areas identifies that individual needs are being met on a continual basis at this home. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Individual care is planned and delivered with dignity and respect. Individual health care needs are monitored and met and access to specialist services is provided as required. EVIDENCE: A random selection of 2 care plans from each of the three units was examined. The standard of care planning throughout all of the units was very good. Care plans had been developed from the initial assessment of needs and there was evidence of risk assessments and both long and short-term plans were in place to address identified problems. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 12 There was evidence of communication with families and the next of kin/representative was able to join in on reviews where individuals were unable to represent themselves. One of the residents who had lived on the residential care unit for a number of years and whom the inspector met with at the last inspection – confirmed that she felt very well cared for and that the standards had remained high within the home. She felt that she was treated with dignity and respect and that her independence was encouraged wherever possible. She went on to say that it was the small things staff did which made all the difference. When her son had married abroad and she had been unable to attend – one of the care staff had brought in some champagne so that she could celebrate the event. A discussion was held with a resident who was receiving nursing care on the second floor unit. The care he was receiving was reflective of the care planned in his care plan. He stated that he had been very poorly and had recently had a spell in hospital. He went on to say that he was “very glad to get back” to the home. He confirmed that he was comfortable and was satisfied that the staff were meeting his needs. Observation of the care received by the residents on the residential mental health unit identified that the staff were respectful, caring and sensitive to the needs of the residents. Sometimes the behaviour of these individuals can be very challenging and the staff were professional in their approach, but at the same time the unit resembled one big happy family. One of the care plans on the nursing unit identified that a dietician had been involved as the resident required enteral feeding via a PEG. Other care plans identified that other healthcare professionals had visited including GPs, chiropodists, optician and referrals had been made where required, such as to the psycho geriatrician. The medication procedure was examined on all three units. The senior care assistant was observed administering the morning medication to the residents on the residential mental health unit. The procedure was discussed with her and she was found to possess the required knowledge and skills for this. She had received the necessary training for the administration of medication. Medication Administration Record (MAR) charts had been completed as required. On the residential care unit one of the residents was self-medicating. She had done this for some time – since admission. A risk assessment had been carried out and this was seen contained in her care plan. She explained to the Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 13 inspector how she appreciated being able to do this, and maintain her independence. On all the units the staff were found to be polite and respectful toward the residents. The residents spoken to confirmed that that staff treated them with dignity and respect and there was evidence that residents were given choices and privacy. It was identified that one of the residents who had lived on the residential unit for many years had moved to the residential mental health unit since the last inspection. The needs of this lady had changed dramatically over the last few months. This lady used to request a visit from the inspector and loved to chat and talk during the visits. Examination of the care plan identified that this lady had undergone a thorough assessment by the staff and also by a psycho geriatrician who had made a diagnosis. By moving this lady to another unit the home was able to continue to meet her needs without the distress of having to move to another home. The relatives of this lady visited the home at lunchtime and spoke at length with the inspector. Despite being obviously upset at the mental deterioration of their relative, they were very pleased that she had been able to stay at the home and they were happy that the home was meeting her challenging needs very well. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are helped to maintain independence and autonomy wherever possible and there was evidence that diverse needs are met. There is a need to review the meals served at the home. EVIDENCE: The home employed two part time activities co-ordinators to oversee and deliver the programme of activities. This programme was extensive, well planned and included outside entertainers. At the time of this unannounced visit, entertainers were visiting the home for an afternoon performance and many of the residents from all three units were sitting watching this in the lounge on the nursing unit. Discussions with residents identified that they were always asked if they would like to attend performances or join in activity sessions. One lady stated “sometimes I do and sometimes I don’t – just depends on how I feel, but Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 15 there’s no pressure either way.” Another resident explained how she is not really interested in the activities but prefers to do her own thing in the privacy of her own room. She went on to say that staff respect this and help her with her own pursuits – like reading by bringing in books for her. Examination of care plans revealed that residents are encouraged to continue with their hobbies and interests as much as possible at the home. There was written evidence that the programme contained Church services at the home and in care plans spiritual needs were identified and met. There were various written examples of how personal autonomy and diversity is maintained at the home. The inspector also witnessed this. In relation to two residents –a gentleman and a lady who had lived together for many years and had both entered the home. There were no double rooms but each one had a single room and used each other’s rooms and were free to come and go between rooms. The unit manager explained how the staff respect their privacy and are always careful to knock on the door and wait to be asked to enter. Another example was, at the time of the visit, the unit manager was heard dealing with a telephone call from a resident’s solicitor and relaying this to her. She was careful to close the door so that the conversation about what the solicitor had said was confidential. This was carried out professionally and with discretion. Individuals were also offered choices in relation to the meals served at the home. The quality of the food served was observed at the time of the inspection to be wholesome and varied. However, it was noted that, one of the choices was “toad in the hole” and this was presented as a sausage in a Yorkshire pudding. Some of the residents expressed their disappointment with this. This was discussed with the manager at the time and she stated that this dish would be reviewed and changed. The completion of the comment cards and comments received from some of the residents indicated that there were mixed feelings about the standard of the meals served at the home and that there was still some room for improvement in this area. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families can be assured that any concerns they have about the home will be listened to and acted upon. The recording of this requires improvement. The systems in place help to keep the residents safe from harm or abuse. EVIDENCE: The home had a complaints procedure in place that was available to residents and relatives. The home maintained a record of complaints and the outcomes. However there were more complaints recorded in the record than there were outcomes for. One of the managers was aware of these complaints and although they had been addressed the absence of recording in the records had been an oversight. The records of those complaints shown demonstrated that they had been addressed promptly. The home had procedures in place to respond to any instances of adult protection. Discussions with staff and examination of a sample of personnel files confirmed that staff had received information about signs and symptoms of potential adult abuse. Staff were aware of actions to take should they have any concerns of this nature. Staff had also received information about the Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 17 home’s whistle blowing procedures. The home’s recruitment and selection procedures ensured that all staff were subject to a police check and that the register of persons unsuitable to work with adults was checked. The home’s procedures and practices for safeguarding residents’ finances was assessed and this showed the home had robust procedures in place Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 25 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has been adapted to meet the needs of the residents individually and collectively and continues to improve in this area. The immediate requirement in relation to the heating system was addressed and this has improved what was otherwise a safe, comfortable and suitable environment, although there is still room for improvement in relation to cleanliness of the laundry area. EVIDENCE: The home provided a generally high standard of accommodation. The home had a welcoming foyer and communal rooms were well decorated and quite homely. Externally there was a rear garden that had a raised area where Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 19 residents could take part in gardening. It was noted however that some areas of the home were cold and some of the residents were feeling the cold. It was identified to the inspectors that the central heating boilers were in need of improvement and were not functioning to full capacity. An immediate requirement was left at the home to address this within 7 days The home have since remedied this and the boilers are now working properly. All bedrooms were for single occupation although the home had a number of adjoining rooms that could be used for couples. Observation of a sample of bedrooms showed them to be well decorated and of a good size. Bedrooms had adequate seating provided and had suitable storage accommodation. Residents spoken to said they liked their bedrooms and that they could bring in small items of furniture. Bedrooms seen were well personalised with ornaments, family photos, pictures and several were brightened up with plants and flowers. Most bedrooms had TVs. All bedrooms had ensuite facilities. Residents were able to access all areas of the building but tended to remain in their respective units except to take part in some organised activities. The home was in the process of making environmental changes to the mentally frail unit to try and make it easier for the residents. All bedroom doors were being painted in bright colours and were to have a picture on the door to help residents recognise their rooms. Also the doors of toilets and bathrooms were being painted in the same colour to assist residents to be able to identify these rooms. All the bedrooms and communal areas were clean and tidy and the home had suitable procedures in place to control the spread of infection. The home had a large laundry, which was adequate to meet the laundry needs of the home. The washers were able to wash at disinfectant levels. There were however some areas of this that needed cleaning. Dust and cobwebs were noted in the area near the main sink and the basin was dirty. There was also some rubbish lying around the laundry and behind the washing machines and driers was dirty. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The needs of residents are met individually and collectively by the numbers, skills and competencies of the staff provided by the home. Residents are protected by the robust recruitment procedure adopted by the home. EVIDENCE: The home provided suitable staffing levels to support the residents on the units. On the nursing unit there were two qualified staff on each shift. In addition there were seven care staff on the early shift, five on the late shift and two on the night shift. There were three care staff working on the mentally frail unit during the day and two care staff at night. The residential unit had fourteen residents and one currently in hospital. There were two care staff on duty throughout the day and one at night. They could call for assistance form the other units if needed. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 21 In addition the home had a range of ancillary staff including domestic, catering and administrative staff. The home operated a robust recruitment and selection procedure. A sample of six personnel files was inspected. All files contained fully completed application forms, a health check and confirmation of identity. In all cases the home had obtained Criminal Records Bureau checks and Protection of Vulnerable Adult checks for those staff employed following the records introduction. All files contained two references. Staff were provided with a job description and a contract. All staff received a copy of the Social Care Council Code of Practice. Examination of the records and discussions with staff confirmed that staff had received induction training that included training in the principles of care and safe working practices. Staff that undertook medication administration had received the necessary training. Many staff had received training in dementia care practices. The home had approximately 33 NVQ qualified but once the current staff complete the qualification the home will fully meet the standard. Additionally the home had a number of overseas staff who had care related qualifications and the home was in the process of ascertaining the status of these qualifications. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the residents who live there. The requirement in relation to the temperatures of the hot water system has now been addressed but there is a need to maintain consistency with fire safety checks. EVIDENCE: The home had two registered managers that worked on a job share basis. Both had been in post for some time and were working well together. They Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 23 were providing consistent management and were well regarded by staff. They were well supported by the Unit Managers appointed to each unit. The home had comprehensive systems in place to monitor and evaluate the service provided. Care practices and healthcare issues were regularly reviewed. These included sampling of care plans, audits of pressure sores and pressure relieving equipment, monthly audits of the medication practices and accidents and complaints. In addition the managers held weekly surgeries providing relatives with the opportunity to speak with the manager should any issues arrive. The home also undertook regular surveys of residents and relatives. There were also a three monthly relatives’ meetings. Outcomes of these systems were acted upon and the home developed action plans to address areas for improvement. The home’s arrangements for safeguarding residents’ finances were inspected. Sampling showed that the home was keeping suitable records of residents’ savings and of any expenditure. Checking showed that receipts supported all expenditure and that the cash held corresponded with the records. The home had Health and Safety procedures in place. Staff had completed the necessary health and safety training including moving and handling, food safety and fire. Infection control training was scheduled for early 2007. The home had undertaken the required servicing of fire equipment although there were two gaps in the fire alarm and emergency lighting checks. This had occurred when the handyperson had been on leave. Evacuation drills were taken place every month. The home was recording accidents and analysing them monthly to ascertain whether practices needed to change. The home was undertaking monthly checks on the temperature of hot water and the records showed that temperatures were inconsistent with the temperatures varying from some being quite low to some being above the accepted range. The latest records showed that the water in the basins of eight bedrooms exceeded the accepted range. The home was aware of the difficulties with the water temperature but had not been able to rectify the problem. An immediate requirement was left to improve this within 7 days and this was addressed by the home within the timescale. Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 4 x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x x x x 2 2 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 2 Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. 2 3 Standard OP16 OP26 OP25 Regulation 22 Requirement Timescale for action 20/01/07 20/01/07 20/01/07 4 OP38 5 OP38 6 OP15 The provider must ensure that the actions taken to address complaints are always recorded. 23(2)(d) The provider must ensure that the laundry is kept clean and tidy. 23(2)(p) The provider must ensure that the home is kept adequately warm. Immediate Requirement left 23(4)(c)(v The provider must ensure that ) all fire checks are undertaken and recorded as per fire regulations. 13(4)(c) The provider must ensure that the temperature of hot water is maintained within the required range. Immediate requirement left 16(2)(i) The standard of the meals provided at the home must be reviewed with the wishes of the residents taken into account. 20/01/07 20/01/07 20/02/07 Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to standard Good Practice Recommendations Rowan Court Nursing & Residential Home DS0000026963.V323734.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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