Inspection on 13/12/07 for Rowans Care Centre

This inspection was carried out on 13th December 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

Rowans Care Centre 21/08/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rowans Care Centre Merriden Road Macclesfield Cheshire SK10 3AN Lead Inspector June Shimmin Unannounced Inspection 13 December 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rowans Care Centre DS0000069626.V354206.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. Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowans Care Centre Address Merriden Road Macclesfield Cheshire SK10 3AN 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) 01625 422284 01625 427006 Canterbury Care Homes Ltd Care Home 30 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (30), Physical disability (10) of places Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing: Code N, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP (maximum number of places: 30). Physical disability: Code PD (maximum number of places: 10). Dementia: Code DE (maximum number of places: 5). The maximum number of people who can be accommodated is: 30. Date of last inspection 3rd October 2007 Brief Description of the Service: The Rowans Care Centre is in a residential home on the outskirts of Macclesfield town centre. It is run by Canterbury Care Homes Limited, which took over as the new owner in June 2007. There are local shops within walking distance of the home and a wider range of facilities in the centre of Macclesfield. The home is on a bus route. The home has two floors with a passenger lift and three staircases between them. The central core of the home has 8 single rooms and one double room. There are two separate lounges on the first floor and a dining room on the ground floor. There are two wings to the home, each with ten single bedrooms and a lounge. There is wheelchair access to all parts of the home and a variety of aids and adaptations around the building so that the people who live in the home can move about as independently as possible. There are open gardens to the front and rear of the building. The current weekly fees range from £390 to £600. Further details regarding fees are available from the manager. Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on 13 December 2007 and lasted nearly seven hours. A CSCI pharmacist inspector accompanied the lead inspector to carry out an inspection of the management of medicines in the home. A short, focussed inspection has been carried out since the last main inspection to check on what action was being taken to meet requirements made at the last main inspection about the management of the medicines. The visits were just one part of the inspection. Other information received about the home was also looked at. Before the last visit the home manager had completed a questionnaire to provide up to date information about Rowans Care Centre. CSCI questionnaires were also given and sent to people who live in the home, their families, and health and social care professionals such as social workers and doctors, to find out their views. During the visit, various records and the premises were looked at. A number of people who live at the home and their relatives were spoken with and they gave their views about Rowans Care Centre. What the service does well: People who live in the home and visitors think highly of staff who work there. People say that staff make sure that their privacy and dignity are respected so that they know they are well cared for. People who are looking for a care home are given information about the home so they can decide if their needs will be met at the home. The manager visits people wherever possible to carry out an assessment of their care needs before they move into the home to make sure their needs can be met there. People say that the standard of catering is generally good so they have a good diet. There is a complaints procedure for the home so that people know they are being listened to and that their concerns will be taken seriously and acted upon. Staff are given support to undertake training relevant to their role so that they are competent to perform their job. Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The care plans for each person who lives at the home must cover all their identified care needs and describe the actions to be taken by staff to meet those needs. These care plans must include details of any risks and the actions to be taken to manage those risks. All care plans and risk assessments should be reviewed at least monthly so staff can check that the care provided continues to be effective for each person who lives in the home. Continued action is needed to ensure residents are protected by the arrangements at the home for handling medication. No member of staff can start working at the home unless full checks have been carried out so that people who live in the home can be confident that staff are suitable to work with them. The manager must apply to the CSCI to become registered, as required by law. Action must be taken to make sure the home is secure and safe in case of fire. External and internal doors must not be wedged open at any time unless there is written agreement to this from the fire authority or there is someone in attendance at all times. An up to date fire risk assessment must be provided to show that all risks have been taken into account and appropriate action has been taken to check fire safety. Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 7 All staff must undertake up to date training in fire safety so that they know what to do to protect the people who live in the home if a fire breaks out. The manager must inform the CSCI of any significant events at the home as required by the regulations. 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. Rowans Care Centre DS0000069626.V354206.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 Rowans Care Centre DS0000069626.V354206.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): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is information available about the home so people can decide if the home is suitable for them. An assessment of people’s needs is carried out before they move into the home to make sure their needs can be met there. EVIDENCE: Up to date information has been put into the information about the home since the change of ownership and this is displayed in the statement of purpose for the home displayed in the entrance. A separate service user guide is given to people or their relatives when they move into the home. This tells people about the daily routines in the home and the facilities provided. The manager carries out assessments of people’s care needs usually before they are move to the home. In an emergency this information might be relayed by telephone. The assessments of two people were checked during the inspection visit. One was for someone who had already moved to the home Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 10 and the second for someone waiting to move in. The content of the assessments was good and provided sufficient information about each person’s needs so that a care plan could be drawn up. There was a detailed social history for one person. This is good practice and helps the home to provide individualised care based on that person’s unique needs. Rowans Care Centre DS0000069626.V354206.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): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans lack detail so that the care needs of people are not sufficiently detailed and people may not be receiving the care they need. EVIDENCE: We were told that all care plans but two were up to date but that an audit of care plans has not yet been carried out so that it might be difficult to show that all care plans were up to date. Three care plans were checked during the inspection visit. The first care plan was for a person whose assessment before moving in had already been looked at. They had been living in the home for eight weeks. Although there were daily records about the care that had been provided for this person, there were no care plans so that staff may not be clear about the care that should be provided. The assessment showed the person had at least twelve care needs that should have had a care plan. Only two risk assessments had been fully completed and neither had been reviewed since Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 12 the person had moved in so that there was no evaluation of how they had settled into the home and whether these risks were being well managed. The second care plan was for someone who had lived at the home for nine months. This was of a better standard and care plans were provided for most identified needs. However, the care plans being used were pre printed and had not always been amended to reflect the person’s individual needs. For instance one care plan identified that a “mini-mental test” should be carried out but there was nothing to show that this had happened so that the person’s ability to understand had not been fully assessed. Several risk assessments had not been reviewed to find out whether actions to meet risks were being evaluated. The third care plan seen was for someone with unstable diabetes. The care plans were again pre printed and there had been little attempt to individualise the care plans so that they accurately reflected the care needs of the person. There were no care plans for the management of diabetes, the side effects of unstable diabetes or for nutrition. The risk assessment for nutrition inaccurately identified the person as being at low risk but they were at high risk because they needed to lose weight to manage the condition better. Not all risk assessments had been reviewed regularly so the person’s changing needs were not always recorded. There was little recorded on care plans about the support and guidance provided from other health care professionals. We were told this was due to care planning documentation being changed to a new system. We were also told that nobody living at the home currently has a pressure sore, which indicates that people at risk of developing pressure sores were receiving good care. During a tour of the building it was noted that staff knocked on the doors of people before entering which showed respect for people’s privacy. Although CSCI survey forms were sent to a number of people to ask for their views about the home, none were returned. When we spoke with people during the inspection visit, they said that they received good care. One person said, “very willing, very nice.” A CSCI pharmacist inspector visited the home to check the management of the medicines as problems had been found at previous inspections. There are company policies and procedures for managing medicines. These contain some useful guidance for staff but could be further expanded to describe in detail how medicines are managed at The Rowans. The storage and handling medicines had much improved. The supplying pharmacy had been changed and medicines were kept in conventional containers and the quantities held were reasonable for the residents’ needs. Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 13 Many of the records of residents’ medicines being given were of a satisfactory standard. Photographs were mostly available to assist in the positive identification of residents when administering medication. These need to be kept-up-to date and with residents’ permission, the missing photos taken at the earliest opportunity. There were some instances where the recorded audit trail and quantity of medicine held did not agree that might indicate that medicines were not given as recorded. For example, the records for one resident showed that only nineteen doses of a twenty-one-dose course of antibiotics had been given. Another record showed that the person had been given twenty-two doses from a twenty-one dose course. There were also a number of omitted records of receiving and giving medicines, when a record was not supplied by the pharmacy. Hand written entries were not always signed and dated. There were also some items on residents’ records where it was not clear if they were current. The records showed that some medicines were out of stock. Sometimes medicines were borrowed from other residents and one bottle of a liquid medicine had the resident’s name changed on the dispensing label. To reduce the risk of making mistakes medicines must normally be administered from residents’ own pharmacy labelled packs. Rowans Care Centre DS0000069626.V354206.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): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to maintain contact with friends and family and were generally positive about the standard of catering. There was only a limited range of social activities available so people living at the home could lack stimulation and become socially isolated. EVIDENCE: Although good information about the social care needs of people was obtained when they moved into the home, this was not included on their care plans so that their previous interests and activities would not be known by staff. Several carers we spoke to were able to provide very limited information about the social care needs of one person who had recently moved into the home even though this information was recorded. This means that those care needs would be largely unmet. A member of staff provides activities on three days a week. WE were told this includes one to one and group activities. There was however little recorded about these activities. Two people living in the home commented that there was little going on. It was noticeable that most people stayed in their Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 15 bedrooms during the day. During a tour of the building a television was on in a number of bedrooms but people were either not watching or were asleep. One person told us that staff did not come round to talk to residents. Staff hold fundraising events for the Residents’ Fund, including tabletop sales to help raise money for activities. Entertainers visit the home usually once a month. Birthdays are celebrated. There is a church service held at the home once a month. People told us that the catering in the home was of an adequate standard. As workmen were painting the main dining room at the time of the inspection visit, meals were being taken to people in their rooms on trays or to one of the other lounges. We were told these meals were being taken individually so that they were still warm when they got to the room. There were no chairs in the dining room but we were told that a delivery of new dining room furniture was due to arrive at the home very soon. People are offered choice about what to eat. The information leaflet about the home (the Service User Guide) indicates that people have choice about various aspects of life in the home such as being able to go to bed and get up when they wish, observing religious beliefs and bringing pets into the home. On the day of the inspection visit, there were three cats and one dog in the home belonging to staff members but there was nothing to show that the views of people living in the home had been sought about this. Rowans Care Centre DS0000069626.V354206.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are procedures in place at the home to ensure that complaints are handled well and action taken to protect people from abuse. However, not all staff have received training about safeguarding adults so may not know what to do if abuse is suspected or found. EVIDENCE: The complaints procedure for The Rowans Care Centre is displayed in the entrance to the home. The complaints log showed that complaints had been dealt with within the appropriate timescales and that actions had been taken to put matters right. The policy for the protection of vulnerable adults has recently been revised. Some of the content is unclear so staff may be unaware of their responsibilities. Important contact telephone numbers were missing form the guidance so staff might not know who they needed to contact. We were told that some staff had done recent training on safeguarding adults, in September 2007, but the training chart was not up to date so it was not clear how many of the staff had received this training. Rowans Care Centre DS0000069626.V354206.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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements need to be carried out to the environment to ensure that it is a comfortable and pleasant living environment for people in the home. EVIDENCE: At the last inspection the Operations Director of Canterbury Care acknowledged that most parts of the home were shabby in appearance and told us that Canterbury Care was committed to improving the environment for people living in the home to make it more pleasant and comfortable. Some improvements had been carried out, notably new kitchen equipment and new dining furniture was expected before Christmas. However, the overall appearance of the home was still shabby. For instance, many of the armchairs and occasional furniture were stained and damaged. The wood of one door to the outside of the home near the smoking room was perishing. Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 18 Various items were being stored in the home behind areas which were curtained off. These items should have either been removed or stored in an appropriate environment. The home was clean and tidy and there were no unpleasant smells. Hand sanitizers, soap and protective clothing had been provided to protect people from an infection outbreak. Rowans Care Centre DS0000069626.V354206.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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff receive training so they can maintain and develop their skills when providing care. Recruitment procedures are not thorough enough to make sure that new staff are suitable to work with the people who live at the home. EVIDENCE: Care staff are well regarded by people living in the home and relatives. Comments were made such as, “very good, everyone is very kind.” We were told that more than 50 of care staff have achieved NVQ 2 or above in care and more staff are undertaking this training. The chart used to record staff training was not up to date so it was difficult to be sure what training staff had done. Although the home is registered to provide care for people with dementia there was no record about which staff have received training in this subject. This means that they may not have the knowledge and skills to care for people with dementia. Staffing levels appeared to be adequate although it was difficult for both the inspector and a visitor to find a staff member at different times of the morning. We were told this was due to staff members being busy attending to people Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 20 who live in the home. Concern was raised that care staff hours might be decreased which might have a negative impact on people receiving care. The recruitment records of two staff were checked. The security check (CRB) of a nurse who started work three weeks before was not available we were told that it had arrived. An orientation checklist for this nurse had also not been completed so that it was difficult to establish if the nurse had received adequate support and guidance before starting work. Records for a second person who had started work on the day of the inspection visit did not include a second reference. Although an initial security check (POVA first) had been obtained for this person the home was still awaiting the full security check. They told us that the person was working under supervision until this arrived. Rowans Care Centre DS0000069626.V354206.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): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There have been some improvements to the running of the home, but there needs to be a clear plan of how the service will develop to ensure that the changing needs of residents can be met in full. EVIDENCE: The manager is a registered nurse and has been in post for just over twenty months but has not yet completed NVQ level 4 in management. She has not yet put in an application to become registered with CSCI as required by the law. This is outstanding from the previous key inspection. Another concern outstanding from the previous inspection was the issue of fire safety and the fact that fire doors that were wedged open, including the front Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 22 door of the home and the two office doors. This would be a serious hazard in case of an outbreak of fire and also poses a security risk. The manager said that she had consulted with the fire authority, which had confirmed that fire doors could be wedged open provided that someone was in attendance. However, during the inspection visit, there was no one in attendance for some time even though the doors were wedged open. An incomplete fire risk assessment was seen but this did not indicate what actions had been taken to ensure fire safety at the home. Records indicated that the maintenance man had recently started to test and check fire safety equipment. We were told that there had been no fire safety training since October 2006 but that this was to be provided in January 2008. Although all but one staff member had taken part in a fire drill a number of staff had not done one since January/February 2007 so might not be clear about what they had to do to protect residents and themselves if fire broke out at the home. A representative of Canterbury Care has visited the home every month except for November 2007 to look at how well care is being provided for the people who live at the home. This person produces a written report for the manager about progress; the report is made available to the CSCI so we can see what progress is being made to improve the home. The manager held a meeting for people living in the home in September and carried out a survey in the summer to find out their views about the home. The results of the survey have not been summarised so that it is difficult to assess whether any actions have been taken as a result of the survey. The complaints procedure indicated that the manager is available once a week in the evening to meet with people and discuss any concerns. As part of their legal responsibility the manager must tell the CSCI of various issues at the home within 48 hours. However, the manager had only contacted us about one of a number of significant events. We were told that the home does not get involved in the finances of people living in the home and that families are invoiced directly by the owners for any expenses incurred. As the training chart was not up to date the manager was unable to confirm whether staff had undertaken moving and handling training in the last year. There was also no evidence that portable electrical appliances had been tested within the last year which means that people living in the home might be at risk of such equipment being faulty. Rowans Care Centre DS0000069626.V354206.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement Timescale for action 28/02/08 2 OP7 15(2) (a-d) 3 OP9 13(2) All people living in the home must have a care plan which describes how their needs in respect of their health and welfare are to be met. This is to make sure that the people who live in the home get the care they need. (Previous timescale of 21/11/07 not met) Care plans and risk assessments 28/02/08 must be kept under review so that people’s changing needs are recorded. This means the care plans will show that action has been taken to make sure that people’s needs are being met appropriately. (Previous timescale of 21/11/07 not met) Accurate records of medicines in 28/02/08 the home must be kept including a clear audit trail of signed, dated records of receipt, administration or otherwise and disposal of all residents’ medicines to make sure that the medicines are managed safely for all the people who live in the home. (Previous timescale of 23/08/07 not fully met) DS0000069626.V354206.R01.S.doc Version 5.2 Rowans Care Centre Page 25 4 OP9 13(2) 5 OP9 13(2) 6 OP29 19 7 OP31 Part 2Section 2Care Standards Act 2000 23 (4)(a) 8 OP38 9 OP38 23 (4)(d) 10 OP38 37 11 OP38 23(2)(c) Regular audits of the medicines management at the home must be carried out to make sure that people who live at the home are receiving their medicines as prescribed. (Previous timescale of 23/08/07 not fully met) To ensure residents’ health and wellbeing medicines must be safely administered as prescribed. There must be sufficient quantities for each person, to ensure continuity of treatment. No staff can be employed unless all necessary recruitment documentation and security (POVA/CRB) checks have been obtained to make sure they are suitable to work with the people who live at the home. (Previous timescale of 21/11/07 not met) The manager of the home must apply to be registered with the Commission for Social Care Inspection in accordance with the requirements of the Care Standards Act 2000. (Previous timescale of 21/11/07 not met) Adequate precautions against the risk of fire must be taken by not wedging open fire doors when no one is in attendance and by the provision of an up to date fire risk assessment so that people are protected. All staff must undertake an annual refresher course in fire safety so that they know what to do in the event of an outbreak of fire. The manager must notify the CSCI without delay of any significant events in the home as required under Regulation 37 of the Care Homes Regulations. Portable electrical appliances must be tested annually so that DS0000069626.V354206.R01.S.doc 28/02/08 28/02/08 28/02/08 28/02/08 28/02/08 28/02/08 28/02/08 28/02/08 Page 26 Rowans Care Centre Version 5.2 people in the home are protected from any electrical faults within this equipment. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations Records of visits from doctors, health and social care professionals should be kept in a way that makes it easy to identify when these happened, what advice was given and what actions were taken to make sure the advice was followed. Care plans should show how the individual social and leisure needs of people who live at the home will be met. Records should be kept to show that people are given choices in their daily lives, such as what they will eat. All staff should undertake training in adult protection so that they know what to do if they suspect abuse has taken place. The manager should ensure that all staff undertake an appropriate induction before starting work at the home so that they are skilled, competent and know about people living in the home. All people providing care for people with dementia should undertake training in this subject so that they know how to meet the needs of people with dementia. Accurate training records should be kept so that the manager is aware of what training each member of staff has undertaken and what refresher and update training is due. The manager should complete NVQ level 4 in management as soon as possible to demonstrate that she has the knowledge and skills to perform her role. All staff should take part in a fire drill at least twice a year so that they know what to do in the event of an outbreak of fire. All staff involved in moving and handling should undertake an annual refresher course in this subject so that they are competent. DS0000069626.V354206.R01.S.doc Version 5.2 Page 27 2 3 4 5 OP12 OP14 OP18 OP30 6 7 OP30 OP30 8 9 10 OP31 OP38 OP38 Rowans Care Centre Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Rowans Care Centre DS0000069626.V354206.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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