Inspection on 19/10/06 for Rushley House

This inspection was carried out on 19th October 2006.

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

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

Other inspections for this house

Rushley House 19/11/08

Rushley House 02/12/05

Rushley House 26/05/05

Rushley House 08/02/05

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 Rushley House 327 Lancaster Road Morecambe Lancashire LA4 6RH Lead Inspector Mrs Joy Howson-Booth Unannounced Inspection 19th October 2006 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 Rushley House DS0000062629.V307800.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. Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushley House Address 327 Lancaster Road Morecambe Lancashire LA4 6RH 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) 01524 417405 01524 425900 Thackray Care Services Ltd Mrs Fay Lucille Thackray Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 13 service in the category OP (Older Persons) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 2nd December 2005 Date of last inspection Brief Description of the Service: Rushley House is a small home situated in the residential area of Morecambe, accessible to local shops and amenities. The home is a large detached house built over two floors. The home is set within its own very pleasant grounds, which residents can access. There is one main lounge, a dining room and the hallway provides a pleasant and roomy thoroughfare. There is also a separate conservatory. All the rooms are single and six have ensuite facilities. There are toilets and bathrooms on both floors and a range of aids, including a stair lift and bath hoist. The current range of fees are from £310.50 to £375.00. further details over fees can be obtained from the registered provider/manager of the home. Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first site visit and was unannounced so the registered provider, staff and residents were not aware of the visit. The site visit forms part of the overall inspection for the home which makes sure people are being cared for properly and to make sure the home is a safe place for people to live in. As well as the site visit, judgements have been made about the service based on information supplied by the registered provider and from comment cards received from both relatives and a GP. The site visit took place over one day and included taking time to sit and speak with residents, observing staff on duty performing the day-to-day routines, speaking with staff, examining documents held in the home and speaking with the registered provider. The inspector looked around the home, including communal rooms, bathrooms and toilets. The tour also provided an opportunity to find out about any improvements made and to see if the home was a comfortable, clean and safe for people to live in. Two visiting relatives were spoken with during the site visit who expressed their satisfaction of the care their relative is receiving at the home. Additional information was also supplied from a pre-inspection questionnaire completed by the registered provider. The site visit was positive with everyone welcoming, friendly and co-operative during the visit. Rushley House has been assessed as a good home, although a small number of standards have shown shortfalls during this inspection. A number of recommendations have also been made. What the service does well: Rushley House continues to provide a pleasant and homely environment which has a relaxed and friendly atmosphere. The registered owner/manager works at the home on a daily basis which gives an opportunity to talk with the residents and pick up immediately on any concerns or issues. A number of staff have worked at the home for sometime and know the residents well. The home has achieved the Investors in People Award. Residents are able to maintain their own lifestyles and daily routines and staff support is provided, when needed. Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 6 Information supplied by the home confirms that there are a range of policies and procedures which ensure residents are provided with the care they need and respects their rights irrespective of their race, gender, disability, sexuality, age, religion or beliefs. The home is well maintained and homely with communal rooms being accessible to the residents . For the bedrooms upstairs there is a stair lift for the residents to use. There are a range of aids and adaptations to help residents maintain their independence. Residents own rooms are well maintained and homely. Residents are also encouraged to bring in treasured personal items to personalise their rooms. Communal rooms are well decorated and provide a homely and comfortable environment for the residents to use. During the site visit, a number of residents were seen and spoken with and all appeared to be well cared for and content. From discussions with the residents and staff on duty the owner/manager is proactive in ensuring the home is maintained to a high standard and is approachable for any ideas and suggestions. One comment card was received from a relative which confirmed that they are welcomed to the home at any time, can visit their relative in private, are kept informed of important matters and are satisfied with the overall care provided. Discussions with two other visiting relatives also confirmed their satisfaction with the care provided by the staff at the home. What has improved since the last inspection? Much more information is now gained by the home before anyone is admitted for care. Care plans (which contain written information about the needs of the residents and how the staff are to meet these) have now all been re-written and provide much better information for staff to use. Training for staff is now well underway with a number of staff having achieved the National Vocational Qualification level II award. Staff files are also much better organised and information can be found quickly. Staff are now given the opportunity to sit down with the registered provide to look at their individual care practices and to see if any improvements or further help are needed. At this time, training is also discussed and staff can say if there is any training they think they need. Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 7 It is noted that only a very small number of staff have left the home since the last inspection which means residents are cared for by staff who know their needs. Medication systems are safe, although a further requirement has been made later in this report. Activities continue to be developed for residents in the home, although outings remain under review. 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. Rushley House DS0000062629.V307800.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 Rushley House DS0000062629.V307800.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, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures enough information is obtained on prospective residents to ensure their needs can be met. Satisfactory information is provided to residents to enable them to make an informed choice. EVIDENCE: The registered provider carries out assessments. Assessments were examined for two recently admitted residents and found to be comprehensive and containing all the required information. For the newest admission, there are specialist healthcare needs, which the registered provider of the home sought clarification over prior to admission. Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 10 Discussion with one of the newly admitted residents confirmed that the registered provider visited him in hospital and asked about his needs, including religious, cultural and disability. Discussions with two visiting relatives confirmed that when their relative was admitted they were provided with an information pack which included information about the home, the complaints procedure and information for their relative to keep. Discussions with members of staff confirmed that when a new resident is to be admitted information is given over their needs, they are introduced at the point of admission and given the opportunity to talk with the resident to find out about them. The registered provider confirmed the home does not provide an intermediate care facility. Rushley House DS0000062629.V307800.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 good. This judgement has been made using available evidence including a visit to this service. The care plans provide good information over the needs of the residents and how these are to be met by staff at the home. EVIDENCE: Three care plans were examined provided comprehensive information about the needs of the residents concerned. Importantly, the care plans also included information about what the resident can still do for themselves which is helpful for staff to encourage residents to maintain their independence. The care plans examined evidenced that there is a range of healthcare and other specialists which are involved in the day-to-day care of the residents. Daily records for residents were also seen and advice given that staff should record the timing of the entries made. Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 12 Staff spoken with confirmed that they have access to the care plans and are given update information about needs curing their shift handovers. Examination of the drugs stocks and records evidenced that the requirements of the Pharmacist have generally been addressed, although the records for receipt of medications is not being consistently completed. Medication administration records were accurately maintained. Controlled drugs were also examined and found to be accurately maintained and appropriately stored. Medication stocks were orderly and clean and tidy. A disclaimer for the home to administer medications was not seen for one of the residents who had been case tracked. Discussions with one senior member of staff raised concerns that medication may not be being administered in the correct way. This was discussed with the registered provider and advice given. Observations during the inspection noted that staff generally provided care with gentleness and respect. However, one observation was noted when a member of staff approached a resident, told them to follow her and did not provide any further information to the resident until the resident clearly did not understand and asked why. This observation was relayed to the registered provider. Seven residents were spoken with and all confirmed that they were very happy with the staff and said the staff treated them with dignity and respect. Discussions with other members of staff confirmed there is a good understanding of how to treat people with dignity and respect. One member of staff commented that she would ask people if they minded whenever providing care input and would also ask residents what they needed. Two visiting relatives were also spoken with who confirmed the feel the staff treat the residents well and they have had no concerns at all over the care provided. A comment card was also received from a relative which had positive comments throughout. A comment card was also received from a GP surgery who confirmed that (the home has) “helpful, caring staff. My patient is happy with the care provided”. The GP also confirmed that there is always a senior member of staff to confer with; they are able to see their patient in private; staff demonstrate a clear understanding of the care needs; specialist advice is always incorporated into the care plan; medication is appropriately managed by the home and they are satisfied with the overall care provided by the home. Rushley House DS0000062629.V307800.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by the home to have a good quality of lifestyle. EVIDENCE: Daily routines and preferences are included in the care plans examined. These evidenced that residents are encouraged to maintain their own lifestyles as much as they wish and have free access to join in the activities organised by the home. Activities organised by the home include – Tai Chi, mobile library, talking books, games, communion, shopping trips, etc. Discussion took place with the registered provider over recording social and other activities provided which should include noting what people have done on a daily basis and also where staff have provided input - 1 to 1 work (massages, manicures, reading the paper to residents, talking to them) as part of the activities that are provided. Through observation of residents going about their day-to-day routines and through discussion it was seen that residents, as much as they are able, are Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 14 encouraged to maintain their community links. One resident went out to the local shops, other residents were enjoying a Tai Chi session when the inspector arrived. One resident confirmed that Holy Communion has been organised for him by the home and the church representative was visiting this person to administer communion during the site visit. Advice was given that the resident records seem to duplicate information and there may be a way that staff can record care and social information, activities and other pertinent information for individual residents in one place. The registered provider is to consider how this can best be done. Residents spoken with confirmed they are free to take part in activities as they wish and are free to exercise choice over what they prefer to do. Most residents at this home are reasonably independent and enjoy using their own rooms. Residents also confirmed they are able to see their visitors in private and choose who they want to see. There are no restrictions on visiting. This was also confirmed by two visiting relatives confirmed the above. The registered provider confirmed that she has no dealings with resident financial affairs – these are managed either by their relatives or by their solicitor or other independent person. From touring the home it was again seen that each room has been personalised with treasured possessions brought in by the residents. It has already been confirmed that all records are maintained according to the requirements of the Data Protection Act 1998. The menus were seen and appeared to provide a nutritional and balanced diet for the residents. It was confirmed that breakfast is a free choice of whatever the resident wants, as is teatime. There is a main set menu at lunchtime but, being a small home, people’s likes and dislikes are well known and alternatives are offered. The home has a menu board on which the day’s menu is written so that if residents want to have anything different they can ask. Discussions with residents confirmed that they are all happy with the food provided and know to ask if they want anything different. During the site visit, a member of staff spoke with residents about the teatime meal and discussed the various choices on offer. The registered provider is aware that special diets not only include those for healthcare reasons but also cultural and religious reasons. There are no special diets in the home at present but the registered provider confirmed this would be found out at the point of assessment and provided. Observations of the lunchtime meal confirmed that residents are provided with a good meal, in an unhurried way in congenial surroundings. Each table is laid out so that the residents can help themselves to condiments and refreshments. Rushley House DS0000062629.V307800.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know how to voice their feelings and who to go to if they are unhappy. Residents are safeguarded by staff at the home EVIDENCE: It was confirmed that there have been no changes to the home’s complaints procedure and this is on display in the reception area. Discussions with residents confirmed that they knew who to talk to if they weren’t happy and it was also confirmed that any issues are dealt with promptly by the home. Two visiting relatives were also spoken with who confirmed they had received a copy of the home’s complaints procedure in the assessment/admission information provided by the home. Both stressed that they had not had to make a complaint to the home. The home’s complaints book notes down any complaints received and also records actions taken. Staff were aware that home had a formal complaints procedure and knew its location. Staff spoken with stated that if any concerns were raised with them Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 16 they would note the issue in the communication book and also in the complaints book for Fay (registered provider) to deal with. Two complaints have been raised with the home since the last key inspection. Both complaints were investigated by the registered provider who liaised with the appropriate outside agencies as part of the investigation. Both complaints were dealt with within the home’s timescale and were not substantiated. The home has a formal adult abuse procedure and has demonstrated that the safeguard adult’s protocols are followed when an allegation is made. Safeguarding adults is covered within the home’s induction and also other training programmes provided. Discussions with staff confirmed that they knew what to do if any concerns were raised over safeguarding the residents in the home. Rushley House DS0000062629.V307800.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 good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and homely environment for the residents which is well maintained. EVIDENCE: There have been no physical changes to the environment of the home, although the refurbishment and upgrading work continues. Recently the stairs and landing area has been redecorated and the registered provider is currently re-dressing the area and is looking to purchase a new light fitting for the main area which will continue to provide a homely ‘feel’. A tour of the home confirmed that the home is well maintained and provides a pleasant and homely environment for the residents. The main lounge is very Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 18 homely and the conservatory provides a place for residents to sit with their visitors or use this area to enjoy the gardens in wet weather. Individual residents rooms are clean and well maintained, with evidence of residents’ personal and treasured items in place. All areas of the home are accessible to the residents, and a stair lift is in place for those who find climbing stairs difficult. There are some aids and adaptations in place which enable residents to maintain their independence. The registered provider was made aware that one bathroom seems cluttered with aids for use by residents and this could do with tidying up. Discussions with two visiting relatives also confirmed they felt the environment was homely, clean and tidy. Information provided by the provider confirmed the home has an infection control policy in place. The provider confirmed there have been no changes to the existing hygiene and infection control systems in place which previously met the requirements. Discussions with staff confirmed that there is currently a cleaning vacancy which the registered provider is hoping to fill in the near future but until then they are undertaking the cleaning of the home in addition to their care duties. Staff confirmed they have done infection control training and also additional training in MRSA awareness. Staff also confirmed that any issues to do with maintenance are written down in a maintenance book and are attended to promptly. It was noted that one of the upstairs toilets does not have access for visitors or staff to wash their hands. Advice was given to the registered provider that further advice should be gained from the Environmental Health Department over the suitability of using (for example) an anti-bacterial hand lotion for people to use. Rushley House DS0000062629.V307800.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 good. This judgement has been made using available evidence including a visit to this service. Staffing is at a good level, with support and training provided to improve knowledge and skills. A thorough recruitment procedure is being followed which safeguards the residents. EVIDENCE: It was confirmed that staffing levels have been increased during the morning shift from 2 members of care staff to 3. A staffing rota has been provided by the registered provider which confirms this. Discussion has taken place with the registered provider over the management rota for the home and advice given that this should accurately reflect the management hours and when the registered provider is on duty in the home. Discussions with residents did not raise any concerns over the staffing levels and they confirmed that staff attended promptly when needed. Discussions with staff confirmed that there is usually enough staff on duty, although the recent domestic vacancy has put additional pressure on them. Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 20 The registered manager confirmed that she is advertising for a replacement cleaner. Staff also raised the issue that the needs of the residents are also higher and sometimes there is a need for an additional pair of hands in the afternoon and evening. It was recommended that they discuss this with the registered provider to ensure resident’s needs are met during all parts of the day. The registered provider confirmed that 8 members of staff have achieved National Vocational Qualification (NVQ) level II. This equates to 66 of staff being trained and puts the home over the minimum requirements. It is commendable that the home has had a very low staff turnover since the last key inspection, with only one member of staff leaving (through retirement) since then. Two members of staff have been recruited and their files were examined. The following was found. Both files evidenced that all the required checks are being carried out prior to commencement of employment. All staff in the home have had a CRB check and advice was given that any CRB disclosures over 3 years old need to be resent for. The home’s application form needs to ensure prospective staff provide a full employment history. It was also recommended that the home develop an interview record as part of their equal opportunities procedure. The registered manager confirmed that the home is involved in the Skills for Care induction process, and the Induction record was seen for the latest member of staff. All staff have their own individual training file and these were seen in place. Discussions with staff confirmed that most had done the mandatory training and that NVQ and other training is ongoing in the home. Other training included – dementia awareness, Motor Neurone Disease training, medication administration and MRSA training. Rushley House DS0000062629.V307800.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 good. This judgement has been made using available evidence including a visit to this service. The management of the home is good which means residents live in a safe and well-managed home. EVIDENCE: The registered provider confirmed that she regularly updates her knowledge through distance learning, training courses and by reading professional documents/publications. Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 22 Discussions with staff confirmed that most have undertaken mandatory training and further training (including NVQ, skills for care induction and foundation training). Staff also confirmed that fire drills are being held and update fire training has been provided to all staff, including those on nights. The registered provider confirmed that a Fire Risk Assessment has been carried out on the home and that all staff have a written copy of the home’s fire procedure. Radiator covers are now in place throughout the home. The home has achieved Investors in People and since the last inspection has implemented continuous assessment processes, staff meetings, verbal feedback from visiting GP’s and other healthcare professionals. In addition, the registered provider has spoken with the residents about holding resident meetings but these were declined. Records of charges and payments were with the home’s accountant and not available for inspection. However, account sheets for the three residents case tracked were forwarded to the Commission. These reflect that the home maintains appropriate records for the charges and payments made. Staff confirmed that they are now receiving supervision (every 3 months). Supervision records were seen for staff in the home. The registered provider was advised to ensure that the topics outlined in Standard 36 are covered within the supervision session. Information supplied by the registered provider confirmed that all the required policies and procedures are in place. However, no review date was indicated. It is advised that all policies and procedures be reviewed at least every 12 months (or sooner if needed) to ensure they remain accurate and reflect current good practices. The home’s accident book was seen and it was noted that not all accidents are being recorded in this book. This was discussed with the registered provider who stated that only falls that result in an actual injury are recorded. Advice was given that all falls or other accidents need to be recorded as required by the Care Homes Regulations. In addition, the information supplied by the home noted that two residents were taken to the local Accident and Emergency department. Advice was given that the commission is to be notified of any accident that occurs to a resident, as outlined in the Care Homes Regulations 2001. Rushley House DS0000062629.V307800.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 3 8 3 9 2 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 3 17 X 18 3 3 X X x X X X 3 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 3 X 3 X 3 X X 2 Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Medication must be administered according to the guidelines provided by the Royal Pharmaceutical Society. Timescale for action 19/10/06 2. OP38 3. OP38 Medication received into the home must be recorded 17(1)(a) – A record must be made for any Schedule accident affecting a resident in 3(j) the home, whether medical attention is required or not 37(1) The registered person must notify the commission of any occurrence as outlined in Regulation 37 of the Care Homes Regulations 2001 19/10/06 31/10/06 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 OP38 Good Practice Recommendations Daily care records should include the time the entry was made. DS0000062629.V307800.R01.S.doc Version 5.2 Page 25 Rushley House 2. 3. 3. 4. 5. 6. 7. 8. 9. 10. 11. OP12 OP10 OP9 OP26 OP31 OP29 OP29 OP27 OP30 OP33 OP33 Care records should reflect the activities and lifestyles of the individual residents Residents should be treated with respect at all times When the home administers medication a disclaimer form should be obtained from the resident Guidance should be sought from Environmental Health over the provision and suitability of anti-bacterial lotion for the upstairs toilet which has no hand washing facilities The management rota should accurately reflect the hours when the registered provider is on duty in the home Criminal Record Bureau disclosure forms should be obtained after every 3 year period Staff files should evidence the date of commencement of employment The employment of a dedicated domestic cleaner would be a clear asset to the staff at the home The NVQ and other training programmes should continue Policies and Procedures should be reviewed at least annually or sooner if needed The Quality Monitoring system in the home should be further developed to include resident, relatives and other healthcare professional formal feedback Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Rushley House DS0000062629.V307800.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!