Inspection on 04/07/07 for Rowan House

This inspection was carried out on 4th July 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rowan House 19/12/07

Rowan House 26/09/06

Rowan House 24/10/05

Rowan House 18/07/05

Rowan House 30/11/04

Rowan House 17/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Rowan House 9 Darwin Road Shirley Southampton Hampshire SO15 5BS Lead Inspector Anita Tengnah Unannounced Inspection 09:00 4th July 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rowan House DS0000011873.V338747.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 House DS0000011873.V338747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowan House Address 9 Darwin Road Shirley Southampton Hampshire SO15 5BS 023 8022 5238 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) Mrs A Hurley Mr R Hurley Mrs A Hurley Care Home 16 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (16), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (16), Old age, not falling within any other category (16) Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A total of 3 service users in the categories (DE) and (MD) may be admitted at any one time between 55-64 years of age. 26th September 2006 Date of last inspection Brief Description of the Service: Rowan House is a large three-storey older style house situated in a quiet area of Southampton. The service is registered to provide personal care to 16 service users in the older person, dementia and mental disorder categories. Up to three service users can be accommodated from 55 years of age with mental health problems. Accommodation is provided on the ground and first floor of the property with a shaft lift that allows access to the first floor. Mrs Hurley is the registered manager. The home has seven shared rooms and two single rooms, none of the rooms have en suite facilities. They are all fitted with wash hand basins. The home has a kitchen, dining room/lounge on the ground floor and all of these rooms are accessible to service users. There is a small garden at the rear of the service. The current fee charged is £335-£430 per week. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the service was undertaken as part of the inspection on the 4th of July 2007. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, laundry room and bathrooms were viewed. As part of ‘case tracking,’ 5 service users views and the comments of 2 relatives were sought on the day and care records were looked at. Information gained from the Annual Quality Assurance Assessment (AQAA) was also used and included in this report, as was information gathered by the commission since the last inspection, to contribute in arriving at judgements in this report. The commission received 6 comment cards from relatives and healthcare professionals as part of the process of seeking their views. The comments were positive and interaction observed at the time of the visit showed that the staff and service users have developed good relationships with each other. Care was provided in a respectful manner. What the service does well: What has improved since the last inspection? The system of care planning has been developed and provided good information about the needs of the service users. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 3,6 The home has an understanding of the service users needs using core admission processes. The service does not provide intermediate care. EVIDENCE: The inspector looked at 2 service users’ care plans and each individual had an assessment prior to moving to the home. The assessments contained some information about the needs of the individuals. Other information available included discharge letters on transfer to the service. The home offers the service users the opportunity to visit the home prior to admission as part of the pre admission process. The manager said that one of the service users did Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 9 spend a day at the home but no record of assessments undertaken during that visit was available in her records seen. A relative spoken with said that the home provided adequate information prior to her mother moving into the service. The manager said that care managers’ assessments would be secured as appropriate as part of the assessment. The home does not provide intermediate care. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 7,8,9,10 The service users’ care plans describe the support service users need. The lack of risk assessments in moving and handling, and consent for the use of bedrails, is detrimental to the service users’ safety. The healthcare provision and access to external healthcare professionals is well managed. The medication management is poor and poses serious risks to the service users’ welfare. The service users say that there are treated with respect. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 11 EVIDENCE: The records of 4 service users were examined and these documents included the plans of care that had been developed for the individuals following the admission to the home. In all the care plans seen there were general risk assessments in place including falls assessments. The care plans contained details such as service users’ likes and dislikes and a personal profile, weight and end of life arrangements. There was evidence that one of the service users’ daughters contributed to her personal profile as she had dementia. The care plans for personal care should be further developed to reflect choices offered to the service users in personal care such as clothing. Two of the relatives raised issues about the lack of involvement in care plans for their mother. This was discussed with the manager. A system to assess the moving and handling needs of the service users must be developed in order to ensure that this is carried out safely. Care records indicated that most of the service users needed assistance with bathing and an assisted bath. Another service user needed a hoist, as it was noted that there was a hoist in the bedroom and the manager confirmed that she needed hoisting at times. There were no records to indicate how assessments of these needs had been reached, and how many carers would be required to carry out this moving and handling of the service user safely. It was noted that a number of the service users had bed rails in place and some of these did not have safety bumpers fitted. This was brought to the attention of the manager and a review is required and action taken to ensure the safety of the service users. There was no evidence that consent for the use of bedrails had been sought and this must be put in place to reflect that autonomy and choice have been considered. Any type of restriction of the service users movements must be within a risk assessment framework and their consents gained. Information received from the AQAA indicated that all the service users are registered with three GPs surgeries. The GP was available on request and the manager reported that some of the service users attended the surgery in the community. One of the relatives spoken with said that she had returned after taking her mother for a doctor’s appointment. The manager reported that the service users medications are reviewed on a yearly basis. The manager reported that the health care professionals supported them and advice and treatment was available as required. The care plans also contained details of visits from healthcare professionals to inform practice, including GP visits. The manager confirmed that there was no service user with pressure ulcers at the time of the visit. Pressure relieving equipment was observed in use for some people as a preventative measure. Comments received from external professionals included “the standard of care is excellent”. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 12 A sample of the Medication Administration Record (MAR) sheets was looked at as part of this visit. There was a record of medication received at the home and the home was using the monitored dosage system (MDS) for the service users’ medication. Records of MAR sheets raised serious concerns about the management of prescribed medication at the service. An immediate requirement was made at the end of the visit. The concerns were that prescribed blood- thinning medications were poorly managed, and in three instances there were no records of the medication being administered. There was a lack of recording for a number of other medications that had been prescribed for the service users. The staff were reminded that accurate recording of varied dosages must be maintained in order to inform practice. At the time of the visit there were a number of ointments and topical creams found in shared rooms that did not belong to the service users in these rooms. This was brought to the attention of the person in charge and these were removed as this has the potential of posing infection control risks to the service users. It was evident that there is no audit of medication at the service and medication is not always returned to the pharmacy, as staff reported that some of the prescribed ointments found in the hairdressing box belonged to people who were no longer there. A requirement was made at the last visit in September 06 that the manager must undertake regular audits of medication records and practices and request the pharmacist to undertake an audit of the medication records and practices. Another requirement was that the manager must ensure staff are fully competent and trained to administer medication. The manager reported that not all the staff had completed medication training, although some of them were responsible for the management of medication. Medication training had been arranged for the end of July 07. The manager was made aware that it was her responsibility to ensure staff competency in the management of the service users’ medication. Both of these requirements have not been met and are repeated in this report. Comment cards received and staff interaction seen at the time of the visit indicated that the service users were treated with respect and offered choice of drinks and where to sit. Relatives spoken with on the day said that they were “very happy “ with the care and they believed that the service users received the support that they needed. Comments included “staff are kind and friendly”. Another comment was “mum is settled and well cared for”. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 The social and recreational needs of the service users are adequately met. Contacts with family are encouraged and supported. Meals are good, well balanced and meet with the satisfaction of the service users. EVIDENCE: There are some activities available to the service users. These included music and movements, hand massage and sing along. A staff member came in on the day of the visit and undertook a short session of music and movement that appeared interactive. The manager reported that the carers mostly undertook the activities. Staff also accessed the local library and brought in DVDs for the service users. A lady spoken with said that she read her newspapers and watched television. Another lady said that she did some knitting, but two others said “there is nothing much to do,” but watched television. Two of the Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 14 service users were observed doing bits of washing up in the kitchen that they appeared to enjoy and one commented that she liked “helping out”. According to the AQAA received all the service users are from a Christian denomination. The manager reported that the vicar attended the home on a six weekly basis and a service was available for the service users. The nuns also visited and took Holy Communion with some of the service users. The views of two visitors were sought on the day of the visit and comment cards received indicated that they were satisfied with the care. Comments included “we are very happy with mum’s care”. “The staff are very friendly and caring”. It was evident from interaction observed that staff and relatives have developed good relationships and are supportive. The home has an open visiting policy. Records in the visitors’ book and comments from the visitors supported this. The manager reported that there is a planned menu in place; the record seen was for a three weeks menu. Meals are taken in the dining area whilst a number of the service users remain in their chairs in the lounge area. The lunchtime meal was observed on the day of the visit. Meals appeared well presented, appetising and wholesome. Service users expressed a high degree of satisfaction with the meals provided. Comments from the service users included that the food “was always good”. The manager said that she was responsible for all the food shopping and bought fresh vegetables twice a week. The home had a list of what the service users have chosen for the teatime meal, however this did not apply for the lunchtime meal. Staff said that they “knew” what the service users liked and would offer them a choice if needed. The manager must look at ways of offering meal choices to the service users and maintaining accurate records of food provided. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of complaints within the home is poor. There is no record to demonstrate that complaints are investigated. There is some training in the prevention of abuse and further staff training is needed. EVIDENCE: The home has a complaint procedure in place; the staff, and five of the comment cards received, said that they would approach the manager if they had any issue. One of the comment received indicated that the manager was not approachable and would contact the commission. It was noted that the home did not have a complain log available as required. Information from the AQAA indicated that the home had received two complaints, however there were no records of these at the home. The manager discussed that the family of a service user had raised concerns with adult services and an investigation was undertaken through adult protection protocols. There was no record of this at the home. The manager reported that the relatives of a service user had raised some concerns with her about the care of their mother. However there was no evidence to show what action had been taken to resolve these. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 16 The manager must ensure that there is a record of all complaints received, any investigation undertaken and their outcomes. The home’s staff are aware of what constitutes abuse and would report to the manager. Some of them had completed training in the prevention of abuse, however this training must be further developed to ensure that all staff have the appropriate training to safeguard the service users. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was homely and furnishing was appropriate to the service users needs. The storage of equipment in the service users’ bedrooms needs to be addressed. The infection control procedures and the poor laundry facility pose risks to the service users’ welfare. EVIDENCE: A tour of the building was undertaken as part of this visit. The service users’ bedrooms seen were in good state of repair and furnishings were appropriate to their needs. Information from AQAA indicated that the provider had refurbished some of the bedrooms. The service users bedrooms seen were personalised and screens were available in the shared rooms. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 18 It was noted that unused furniture, a bed and a hairdressing trolley/hair drier were being stored in the service users’ bedrooms. The manager reported that the bed was no longer used as the sleeping staff slept in the lounge. The manager must ensure that the service users personal rooms must not be used to store equipment and a storage facility must be looked into. The lounge area was being used as the “sleeping room” as there is no other room for the staff to use. The home has two separate areas where laundry is undertaken. The laundry rooms were in poor state of repair with flooring that was not impermeable and posed infection control risks. The laundry was dusty and there was a poor ventilation system in one of them. The manager discussed the plans to refurbish and extend the laundry but there was no set date for this. It was also noted that access to the laundry was through the kitchen and dirty/ soiled laundry passed through the kitchen and posed high infection control risk. The home’s infection control practices need to be reviewed and procedures put in place for the handling of soiled laundry, to include staff training in infection control and the prevention of spread of infection. The manager was advised to seek advice regarding infection control and the management of soiled laundry. A risk assessment regarding transportation of soiled laundry through the kitchen must be put in place to inform practice and safeguard the welfare of the service users. As part of infection control management the manager must use disposable hand towels and soap in all communal areas as identified at the time of the visit. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels need reviewing as they are not adequate to meet the present needs of the service users. Care hours are eroded by non- care duties. Staff and the service users have developed and maintained good relationships with each other. The home has a good recruitment process in place. There is a staff-training programme in place, however this must be further developed in particular with regards to medication management. EVIDENCE: The home had 16 service users in residence at the time of the visit. Staff reported that there are 2 carers during the day and 1 waking carer and 1 sleeping carer during the night. Information from the AQAA indicated that there are 11 service users with high care needs and 4 service users that required 2 carers to attend to them. The manager lives on the premises and said that she is available when needed. The duty roster showed that the chef worked from 10:00 –13:30 4 days a week and some weekends. The domestic staff worked 3 mornings a week; the carers undertook the laundry, and the cooking at teatime, and cleaning 4 days a week. Care hours are therefore Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 20 eroded by non- care duties. The last report in September 06 required the manager to undertake a review of the staffing levels against assessed needs of the residents, times of day and staff activity, and ensure staffing levels were sufficient to meet service users’ needs. This requirement has not been met. The manager must ensure that the duty roster reflects accurately the staff hours worked, as there was a discrepancy in the record seen on the day of the visit. The interaction observed and comments received indicated that the staff and the service users had developed good relationships with each other. Staff attended the service users in a sensitive manner and respectfully. Two of the visitors spoken with also said that the “staff are very kind and caring” and “my mum is well looked after”. One negative comment was received about relatives’ difficulty with staff. A sample of three staff records was seen as part of the visit. The staff were those that have been employed since the last inspection. Records showed that all staff completed an application form with details of employment history. All necessary checks were undertaken including CRB and POVA first checks prior to their employment. The manager reported that the home has a training programme for staff. Records seen showed that 3 staff have completed training in medication, 4 completed moving and handling in November 06, and 6 staff had dementia care training in June 06. There was no up to date training record available from November 06. It is recommended that the manager develop a training matrix to monitor mandatory training for the staff. This would help identify any shortfalls and training can then be addressed sooner. The manager reported that NVQ training was available. Information from the AQAA showed that the home has 4 staff with NVQ 2 or above, and 3 staff were working towards this qualification. The manager reported that 2 staff who were NVQ trained had recently left. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a registered manager, however the management is not effective, given outstanding requirements and issues raised in this report. A review of the staff structure and management support needs to be looked into. There is a good process in place to ensure that the service users financial interests are safeguarded. An ongoing programme in place for servicing and equipment check is in place. The management of record keeping was inadequate. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has a registered manager who is also the provider. Information received through the comment cards from staff and relatives spoken with indicated that Mrs Hurley was supportive and well liked. One negative comment was received about the management at the home. Mrs Hurley does not hold the NVQ qualification at level 4 or the Registered Manager’s Award. She discussed that she had intended for a member of staff to undertake this training and act as her deputy but the staff member has since left. The home has a number of requirements from the last visit in September 06 that remain outstanding and there does not appear to be clear lines of accountability within the service. It was evident that the staff do their best to support the service users but they need guidance and leadership. Mrs Hurley discussed that she would look into a review of the management structure and delegate some of her responsibilities to a senior staff member. This would free her to carry on with her manger’s role. A sample of the service users’ personal allowances as managed by the home was looked at. The manager reported that she was an appointee for one of the service users. Their family or advocates deal with the rest of the service users finances. Records of all transactions including receipts were maintained and a random check of balances as recorded showed that these were accurate. All monies were kept safely and the manager reported that she was the only person that dealt with the service users’ finances. Information received indicated that there is an ongoing programme for the servicing of equipment at regular intervals to ensure the safety of the service users. Records showed that the fire officer had visited in April 07 and a recommendation regarding a fire risk assessment for the building had been completed. It was noted that the folder that contained all the staff personal information was not maintained securely as was some of the service users records. The manager was reminded that staff and the service users records must be maintained securely at all times and in accordance with data protection. Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 X X X X X X 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 1 X 2 X X X 2 3 Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 and 17(1) (a) Schedule 3 (k) Requirement Prescribed medication must be available to the service users. Timescale for action 04/07/07 2 OP9 13(2) An accurate record of all prescribed medication, and the times that these have been administered to the service users, must be maintained at the home. Immediate requirement notice. There must be a policy in place 30/08/07 that staff adhere to regarding safe storage of medication. Prescribed medication including creams/ ointments must only be administered to the named service users. 30/08/07 The manager must undertake regular audits of medication records and practices. Medication practices must be in line with guidance from the Royal Pharmaceutical Society. This is a repeated requirement from 31/10/06 that has not been met. 3 OP9 13 Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 25 4. OP9 13(4) (c ) 5 OP16 17(2) Schedule 4 (11) 13(4) 6 OP19 The manager must ensure staff are fully competent in the administration of medication. This is a repeated requirement from 31/10/06 that has not been met. A record of all complaints received at the service and details of any investigation and action taken must be recorded and available. The manager must review the storage of equipment/ unused furniture to ensure that they do not encroach on the service users’ bedrooms space. The laundry room must be fit for purpose. 30/08/07 30/08/07 30/08/07 7 OP26 13(2) 16(2) (j) 30/08/07 8 OP27 18 (1) (a) Infection control policies, training and staff practices must ensure that the service users are not at risk of infection. 30/08/07 The manager is required to review staffing levels and ensure that there are adequately trained staff, and in sufficient numbers, to meet with the assessed needs of the service users at all times. This must include domestic staff. This is a repeated requirement of 31/10/06 that has not been met. All confidential records pertaining to the service users and staff must be securely locked at all times. This is a repeated requirement from 31/10/06 that has not been met 30/08/07 9. OP37 17 Rowan House DS0000011873.V338747.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 House DS0000011873.V338747.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rowan House DS0000011873.V338747.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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