Inspection on 21/06/05 for Rowans Care Homes Ltd TA Bridge, Burton & Trent Courts

This inspection was carried out on 21st June 2005.

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

Rowans Care Homes Ltd TA Bridge,... 16/02/09

Rowans Care Homes Ltd TA Bridge,... 03/06/08

Rowans Care Homes Ltd TA Bridge,... 27/11/06

Rowans Care Homes Ltd TA Bridge,... 28/11/05

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

CARE HOMES FOR OLDER PEOPLE Rowans Care Home Ltd 17 & 18 Ashby Road Burton on Trent Staffordshire DE15 0LB Lead Inspector David Cowser Unannounced 21 & 22 June 2005 09:30 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 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 Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Rowans Care Homes Ltd Address 17 & 18 Ashby Road Burton on Trent Staffordshire DE15 0LB 01283 512915 01283 509330 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Rowans Care Homes Limited Mrs Helen McVay Care Home 67 Category(ies) of 29 DE(E) registration, with number 1 MD of places 27 MD(E) 13 OP 40 PD 40 PD(E) 4 TI Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The Care Manager must complete a recognized course for RGN`S in Dementia awareness and management (EN 35) within 12 Months Statutory environmental standards must be met before occupation of Burton Court, and all work completed within 6 Months of registration For 4 beds (max) in Terminal Illness category; A nurse must be employed with a suitable qualification in Care of the dying (ENB 931). All care staff directly involved in pallative/terminal care must receive appropriate training. Minimum age of service users in TI category 60 years Minimum age of service users in MD category 60 years Minimum age of service users in DE category 60 years Minimum age of service users in PD category 60 years Date of last inspection 7 December 2004 Brief Description of the Service: The Rowans care complex provides nursing and personal care to a maximum of sixty-seven persons over 60 yrs of age. The premises, consisting of a main building (40 beds) and an adjacent building (Burton Court 27 beds), is situated on the Ashby Road near to Burton on Trent. The home, originally two large Victorian family houses, is set in grounds with adequate car parking. Services and facilities including laundry, catering and hotel services are good, with adequate staffing levels. Both buildings are served with a shaft lift, and access to all parts of the buildings is good. The main building is a general nursing home with broad categories of registration, including terminal care. The Burton Court annexe provides care for people with dementia related conditions. The home also contracts for intermediate care beds with the local NHS trust. Activities, hobbies and entertainment all take place and transport is provided when required. Families and friends are encouraged to take part in activities and trips out. Trained nurses, both RGN and RMN, and teams of care assistants provide care. They are all responsible to the registered care manager, who is a first level nurse (RGN). Health service professionals such as district nurse, community psychiatric nurse, and physiotherapist are accessed when required. Several local GP practices and a pharmacist service the home. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced visit was made on the 21 & 22 June 2005 @ 09.30hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 16hrs. The registered care manager was in charge of the home; accompanied by 2 RGN’s, an RMN, 10 care assistants and 2 student nurses. The ancillary staff on duty included; housekeeper, four domestic workers, two-maintenance personnel, cook and two catering assistants. The business support person was also on duty. These staffing levels were adequate to meet the needs of the current 59 residents in the home (38 main building 21 Burton court). The total of 59 elderly residents, aged between 61 and 94 years of age, included 55 nursing patients and 5 people with personal needs. Burton court occupants were receiving care for needs associated with dementia related conditions. Residents within the main building were receiving care for needs associated with physical conditions and chronic sickness. The home also had three intermediate care patients from the local NHS facilities. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with ten residents and eight visitors, discussions with eleven staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection on 7 December 2004 the Burton Court annexe had been occupied with residents transferring from another home (recently closed). No formal complaints had been received. There had been 5 deaths recorded, and two residents currently had a pressure area. No incidents or reports of abuse of any kind had been received and policies and procedures seen covered these issues. No residents had attended an A&E department, and no serious injuries had been recorded. One incident of theft had been dealt with in the correct manner. It was evident that aspects of care had been addressed well, with residents able to choose the home following an assessment and invitation to visit the home. Service user plans had been written, based on the community care plans completed by social workers. Health, personal and social care needs had been met and documented. Further development of the documentation was recommended. Privacy, dignity and choice aspects for residents were being upheld. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 6 The home was fit for purpose and provided a safe environment for the residents and staff. A homely atmosphere had been created, and the premises were clean, warm and tidy. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities, including catering and laundry, were well provided. Both the catering and laundry facilities were in the process of being relocated within the care complex. This work has been agreed with environmental health, fire authority and CSCI, and all necessary checks will be carried out on completion. Health and safety aspects had been given a high priority and no shortfalls were noted. On the day of the inspection the residents and their visitors were not allowed to sit outside and the conservatory was too hot to sit comfortably. A requirement is made to provide a safe and suitable area outside for residents in hot weather. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment and retention of staff aspects were much improved with reduced staff turnover. Staff training is now being given a high priority, with induction training being followed by NVQ training, and staff supervision is now being implemented. The home appeared to be managed well by a competent care manager. General management aspects were good with quality assurance being introduced. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that the company adopted suitable accounting/business procedures. The requirements made on the last report had been addressed with the following exceptions: staff supervision must be completed, quality assurance should be developed, the relocation of the kitchens and laundry should be satisfactorily completed, a sluice machine must be installed, activities and entertainment should be expanded and documented, NVQ training should be completed. Care planning documentation should be expanded and all plans must be reviewed monthly. What the service does well: The home provides a broad spectrum of care and covers all registration categories to meet the needs of the elderly, including palliative care and dementia care. A good atmosphere is now in evidence and there is a good interaction between staff and residents/relatives. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 7 What has improved since the last inspection? 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. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Individual health, personal and social cares needs had been established and were being met by staff, which individually and collectively had the necessary skills and experience. EVIDENCE: The documentation seen, and a discussion with residents/representatives, evidenced that residents had been assessed prior to admission and they had been enabled to make a choice about the home. All involved had the opportunity to visit the home prior to choosing to stay. Several residents spoken to had visited the home, and had a meal prior to deciding to stay, and this was seen documented within the care plans. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. Residents asked confirmed that they had been fully involved and were in agreement with the assessments. The records seen and a discussion with the staff evidenced that care staff, individually and collectively, had the necessary experience and skills to meet the assessed needs of the current service users. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The assessed health and personal care needs of residents had been documented and were being met, with good standards of care being delivered. The psychological assessment section of individual care plans had not all been completed. Not all care plans had been reviewed monthly. There was a safe system for the receipt, storage, administration and disposal of medicines. Residents were treated with respect, privacy and dignity, during the caring process. EVIDENCE: Seven residents, and six relatives spoken to, all commented positively about the care being provided. One family had some reservations, but were currently discussing their mother’s care and the input of the medical profession with the care manager. The service user plans and associated documentation was, meaningful and reflected the current condition of residents. However not all plans had been reviewed on a monthly basis. The psychological assessment section had not been completed for all residents. The documentation seen and a discussion with both residents and staff members evidenced that health and personal care needs were being well met. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 11 NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required. During the inspection a palliative care nurse and a social worker visited and told the inspector of the good working relationship with this home. Several local GP practices and a local pharmacist service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. The medicines within the home, medication administration records, controlled drugs book and drugs returned book, were all checked and no errors were noted. It was observed that a safe system was in place, and that the comprehensive medicines policy documentation seen was being complied with. The documentation seen evidenced that only trained nurses administered medicines. No resident was ‘self medicating’, but locked facilities were available. During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. Two residents told the inspector that they were treated with respect, and that the staff were very good to them. Since the last inspection 5 deaths had been recorded. Two patients were receiving treatment for a pressure area, and no serious accidents had been recorded. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Residents were satisfied with their lifestyle in the home, and they had been able to exercise choice and influence decisions affecting them. Residents unable to make a decision had been assisted by care staff that was knowledgeable on their likes and dislikes e.g. choice of meals, activities. Contact had been maintained with relatives and friends of residents. Catering aspects were very good with balanced nutritious meals being served, along with resident consultation and choice. Activites and entertainment must be developed and facilitated, after consultation with service users. EVIDENCE: Several residents told the inspector that their views had been listened to, and that they had been able to influence some aspects of the running of the home e.g. mealtimes, menus, beverage facilities for visitors. Contacts had been maintained, where possible, with relatives and friends and this was seen documented. Residents spoke of their visitors and their involvement with the home. Several visitors attended the home during this inspection, and told the inspector of the good links and communication with them. The activities were about to be organised by a designated member of staff. The activities folder and programme of events was not available for inspection. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 13 Activites and entertainment must be developed and facilitated, after consultation with service users. Several residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of residents were met. The records evidenced that residents’ needs with diabetes, and special diets, had been met. The cook when asked said that fresh good quality food from local suppliers was delivered on a weekly basis, the records seen confirmed this. Adequate supplies of fresh vegetables and fruit were also seen. The inspector sampled the mid day meal and it was very good, meeting all requirements. Several residents were unable to make a decision regarding choice of meal, due to their current condition, and the inspector saw them being assisted by staff who were knowledgeable of their likes and dislikes. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Complaints or grumbles are listened to and resolved. The home policies, procedures and staff training, protected residents from aspects of abuse. EVIDENCE: An examination of the complaints book, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with in the correct manner. Since the last inspection no formal complaints had been recorded or brought to the attention of this commission. ‘Thank you’ and complimentary cards were seen from appreciative relatives. No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. No residents had attended an A&E department since the last inspection. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and IPR meeting. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 The premises were fit for purpose, with adequate personal and communal facilities provided. The home provided a safe and well-maintained environment for residents. The home was clean, warm and tidy, and had a very comfortable atmosphere. Adequate ancillary staff were employed. The installation of a sluicing disinfector machine within the homes sluice facilities must be considered, as discussed. Further completion/test certificates should be produced on completion of the kitchen and laundry relocation works, as agreed. The grounds and gardens must be made safe and suitable to allow residents and visitors to sit outside during hot weather. EVIDENCE: A tour of the premises, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy. The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked told the inspector of their knowledge on infection control, and showed him the relevant documentation. Adequate hand washing facilities were available throughout the home. The laundry facilities were seen to be fully compliant. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 16 The records evidence that maintenance of the premises was being given a high priority. Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. The fire prevention officer has agreed the changes taking place to the kitchen and laundry facilities. Updated commissioning/testing certificates will be required on completion of this work, as agreed. On the day of the inspection the outside temperature was in excess of 25deg. C. The conservatory was almost unbearable to sit in. Residents had been denied sitting outside due to health and safety considerations. The grounds and gardens must be made safe and suitable, to allow residents and visitors to sit outside during hot weather. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The assessed needs of service users had been met by an adequate number of suitably trained staff. Recruitment procedures for staff had been correctly addressed, which had contributed to the protection of service users. Staff training is now being given a high priority. Training should continue to enable 50 care staff achieve NVQ level 2. EVIDENCE: The duty rosters seen, and a discussion with the manager and the staff, evidenced that adequate numbers of care staff had been on duty to meet the needs of the existing service users. Staffing rosters were checked and were in order. An examination of the rosters evidenced that in addition to the registered care manager the following care staff had been maintained or exceeded for the total59 residents: Main Building a.m. 2RGN 6 Care assistants p.m. 2RGN 5 Care assistants nights 1RGN 9 Care assistants Burton Court a.m. 1RMN 4 Care assistants p.m. 1RMN 4 Care assistants nights 1RMN 2 Care assistants In addition to the above adequate ancillary staff were rostered on duty throughout the week. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 18 Several residents asked stated that staff were available when they wanted them, and that the staff were capable. The records seen evidenced that, in addition to the managers of the home, and trained nurses there were 53 care assistants, of which 12 (22 ) were trained to NVQ level 2 or above. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had not yet received job descriptions and contracts of employment relating to the present company and place of work. It is understood that these will be issued in the coming weeks. Training was now being given a high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training which had covered the needs of the registered client group. Staff told the inspector that they had been afforded the time off and encouraged to study. Training had been provided for staff in the awareness and management of dementia related conditions, and a senior carer outlined this to the inspector. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36,38 The home appeared to be well managed. Financial aspects were correctly addressed and recorded, with safeguards to residents. Health and safety issues had been given a high priority and managed well. The recently introduced system of staff supervision must be implemented, as agreed. The recently introduced quality assurance system should be implemented and service users/representative should be involved, as agreed. EVIDENCE: From observations made, and discussions with service users and staff, it was evident that the home was being run in the interests of service users. Quality assurance, including feedback from residents and their representatives, was taking place but not documented. A revised quality assurance format has been produced and the documentation will be checked during the next inspection. A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Day to Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 20 day monies of residents were checked and money held reconciled with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examination of plant and equipment was all correct and up to date. The staff spoken to confirmed that health and safety issues are given a high priority. It was pleasing to note that the safety of residents, staff and visitors had been safeguarded during the refurbishment work underway. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 2 x 3 Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP26 Regulation 23(2)(k) Requirement The installation of a sluicing disinfector machine within the homes sluice facilities must be installed, as discussed. The recently introduced system of staff supervision must be implemented, as agreed. All sections of individual care plans must be completed, and reviewed monthly. Activites and entertainment must be developed and facilitated after consultation with service users. The grounds and gardens must be made safe and suitable to allow residents and visitors to sit outside during hot weather. Timescale for action 31 March 06 21 October 05 21 August 05 21 July 05 2. 3. 4. OP36 OP7 OP12 18(1)(c ) 15(1) 16(2)(m)( n) 23(2)(a)( o) 5. OP19 21 July 05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP28 OP33 Good Practice Recommendations Training should continue to enable 50 care staff achieve NVQ level 2. The quality assurance system should be developed and E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 23 Rowans Care Home Ltd 3. 4. OP19 OP29 service users/representative should be involved, as agreed. Further completion/test certificates should be produced on completion of the kitchen and laundry works, as agreed. The revised contracts of employment and job descriptions should be isssued to staff, as agreed. Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rowans Care Home Ltd E51-E09 S63566 The Rowans V234370 210605 Stage 4.doc Version 1.30 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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