Inspection on 08/10/07 for Rutland House Care Home

This inspection was carried out on 8th October 2007.

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

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

CARE HOMES FOR OLDER PEOPLE Rutland House Care Home 67 All Saints Road Sutton Surrey SM1 3DQ Lead Inspector Barry Khabbazi Key Unannounced Inspection 8th October 2007 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rutland House Care Home DS0000068599.V352034.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. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rutland House Care Home Address 67 All Saints Road Sutton Surrey SM1 3DQ 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) 020 8644 5699 Rutland Care Home Ltd Dona Dias Kusuma Konthasinghe Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service Brief Description of the Service: Rutland is a care home for up to 20 people with dementia. The home has 12 single rooms and 4 double rooms and is based in a large house on a residential road in Sutton. There is some parking in the homes drive and currently unrestricted parking on the road. The home has recently changed ownership and has been going through a process of modernising and updating to the environment since that time. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for this home since it had changed ownership. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on and any new issues arising. This inspection was unannounced. During this inspection the manager/owner was interviewed. Records, care plans and the building were examined, as were the residents’ bedrooms. No serious concerns were identified at this inspection, see the section ‘what the home could do better’ for details of the minor shortfalls identified. In addition, a number of areas of good practice were already apparent and are recorded in the ‘what the home does well’ section of this report. What the service does well: What has improved since the last inspection? This section usually refers to improvements made relating to requirements previously set. As the Commission treated this as a new home inspection, there were no previous requirements to assist filling in this section. However, it is noted that improvements to the environment included new furniture, a new fire alarm system, decoration of the downstairs, and current decorating of the upstairs. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 6 What they could do better: The front door is kept locked to protect the residents. This fact needs to be recorded clearly in the Statement Of Purpose and service users guide, to ensure that all potential residents and relatives, and any placing care managers all know and agree to this restriction of liberty, before a placement is made. This will ensure that no residents are placed that do not need this restriction for their protection, and therefore that no unnecessary restrictions of liberty are placed on any resident. Staff files need be kept securely on site and be available for inspection. Although the residents’ files were in very good order, the staff files, {particularly those relating to the previous employers} were in poor condition. Although no serious staff vetting concerns were identified, many documents were not easily found and some could not be found at all. Although the home has all the required quality assurance tools, like a complaints system, audits and quality questionnaires for residents and relatives, these now need to be pulled together into a structured Quality Assurance system that makes the service users central to the process. An annual development plan drawn from the quality assurance tools, open to the residents, and meetings to feed this information back to them is needed to convert the tools into a system that achieves this. Standard 25 requires thermostatic mixer valves to be fitted to all water outlets in homes of this type to protect residents from scalding. Bedroom 1 on the ground floor did not have this device fitted and this needs to be addressed by the home. A number of the older doors in the home have a suspected asbestos product fitted to their backs as an old fashioned fire retardant measure. These types of products may cause damage to health and must be therefore sampled, checked and dealt with appropriately. Some rooms had a slight odour of urine in them. The manager was aware of this and has been addressing it since taking over the home. The building was clean and carpets had also been cleaned. More drastic methods may be needed as it is possibly wooden floorboards that are the cause of this through a long term lack of hygiene before the home was taken over by the current owners. Induction and foundation training to National Training Organisation’s specifications needs to be in place. This should create a more highly trained workforce. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 7 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. Rutland House Care Home DS0000068599.V352034.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 Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3, and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The initial assessment covers almost all the elements required. Completing this will result in more detailed and relevant assessments of a resident’s individual needs and a better understanding of their needs by staff. This home does not provide intermediate care with a view to return to the community and Standard 6 is therefore not applicable. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 10 EVIDENCE: Standard 1 was not assessed on this occasion as it is not currently a key Standard and changes to our practices will require a full assessment of this Standard next year. Although Standard 1 was not assessed in its entirety on this occasion, the following information connected to Standard 1 was identified as follows: The front door is kept locked to protect the residents. This fact needs to be recorded clearly in the Statement Of Purpose and service users guide, to ensure that all potential residents and relatives, and any placing care managers all know and agree to this restriction of liberty, before a placement is made. This will ensure that no residents are placed that do not need this restriction for their protection, and therefore that no unnecessary restrictions of liberty are placed on any resident. The following requirement is now set to facilitate this: The fact that front door is kept locked to protect the residents needs to be recorded clearly in the Statement Of Purpose and service users guide. This will ensure that all potential residents and relatives, and any placing care managers all know and agree to this restriction of liberty, before a placement is made. This will ensure that no residents are placed that do not need this restriction for their protection, and therefore that no unnecessary restrictions of liberty are placed on any resident. The home uses an initial assessment form for new residents that is comprehensive and covers all the elements required. This document is also clearly laid out and serves the required purpose. Additional waterlow scores, risk assessments, body charts and barthal scores are also produced. Standard 6 does not apply to this home as this home does not provide rehabilitation with a view to returning to the community. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10, and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care are clearly recorded, holistic, and contain all the information required. Records of the reviews are clearly recorded to identify changing needs. This will help staff know all a resident’s needs and how to meet them. Residents’ personal care needs and physical and emotional health needs are met by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is also well managed to ensure maximised good health. Residents can be confident they will be treated with dignity and respect. The residents’ needs regarding terminal care and following death are met well. Good practice has been identified in treating residents and relatives with respect and sensitivity at times of illness and death. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 12 EVIDENCE: The home uses an initial assessment form for new residents that is comprehensive and covers all the elements required. This document is also clearly laid out and serves the required purpose. Additional waterlow scores, risk assessments, body charts and barthal scores are also produced. Plans of care are clearly recorded, holistic, and contain all the information required under Standard 7. Records of the reviews are clearly recorded to identify changing needs. Good practice identified under Standard 7: Care planning records and service user files were maintained to a high standard, and information within files was clear and easily accessed. The home currently has a good record for maintaining and improving skin viability. There are currently no residents with pressure sores at this home. Pressure sore avoidance procedures include waterlow scale assessments {for all residents}, air pressure mattresses, hygiene and regular toileting, nutritional and fluid monitoring, healthy and nutritious meals and supplements where required. Weight charts were clear and well maintained and weight changes illicit recorded action. Access to specialist health services, for example, physiotherapy, chiropody, dentists and opticians, Community Psychiatric Nurses and Psycho-geriatricians is provided. Opportunities for physical exercise include group exercises and assisted walks. Residents remain registered with their own family General Practitioner whenever it is practicable to do so. Residents are weighed on a monthly basis. Clearly recorded medication records and medication administration record sheets were seen in records sampled. Controlled drugs are used at this home and are stored in an appropriate metal cupboard attached to the wall. The controlled drugs register was present and is double signed as required. Medication and the M.A.R sheets are kept securely in a locked metal dispensing trolley fixed to the wall when not in use. Individual blister packages are used for tablets instead of bottles for easy identification and monitoring. Care staff are required to check the possible side effects of any medication in the British National Formulary and additional information is kept in the medication files. Service users can self medicate subject to a risk assessment. A lockable space is provided in each bedroom to facilitate this. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 13 Staff were observed to interact with service users with respect and dignity. Professionals can meet service users privately in their own rooms or one of the lounges if not in use. Staff are instructed during induction about the priority of treating service users with respect. The service users preferred term of address is used and there are no communal clothes. Procedures are in place for death and dying and these include recording the service user’s wishes regarding terminal care and arrangements after death. Service users are able to spend their final days in their rooms and specialist medical care is brought in if required and appropriate attention to pain relief given. Bereavement counselling is offered where required. Good practice identified under Standard 11: Death and dying of a resident is addressed sensitively. Additional support to that required in the minimum standards includes memorial services available at the home, allowing relatives to continue to visit other residents at the home after the loss of their own relative if they wish, and if a resident does not have a relative to be with them in their final moments and does not want to be alone, staff are provided to sit with the resident so they are not alone in their final moments. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the home will match their expectations, preferences and their cultural religious needs. Residents are provided with opportunities to remain part of the local community and are able to take part in appropriate activities. The daily routines and the home’s policies promote the residents’ choice and rights, to ensure equality and that all rights are enjoyed by all residents. Dietary needs are catered for and a well balanced diet is provided, to ensure health and enjoyment of food. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 15 EVIDENCE: The home has a specific post of activities organiser and activities occur at a rate of at least one per day. Activities include a visiting church service, trips out, games, art, music, bingo, reminisence, the celebration of events, and one to one activities and discussion with staff. Service users can receive visitors in private and there are no restrictions on receiving visitors, except those identified by the service user themselves There is an open visiting policy and visitors are told they can visit at any time. Community activities include, local walks, visits to parks and shopping. The home is run in a manner that promotes independence and choice, and this was confirmed through policies and observation. Service users can take meals, and particularly snacks, at times and places to suit them and have a choice of meals and alternatives. Some residents were seen to be still eating breakfast at 10 am and were not being rushed. Service users handle their financial affairs for as long as is practical or for as long as they wish. The home does not manage any of the service users’ finances. Service users can bring in their own possessions and furniture if they wish and this was observed in their rooms, which had been individualised. Breakfast was observed and was offered in a pleasant setting congenial to the purpose, with a clean environment. Menus were nutritiously balanced. Many service users were seen to eat well and said that they enjoyed the food and that it was usually like this. Meals are regular. Individual alternatives and additional snacks are provided when requested. Special therapeutic diets are provided, although are currently not required. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are managed well which should ensure that residents’ and relatives’ concerns are listened to. The home’s policies and procedures help protect residents from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The home has only received one complaint which was unsubstantiated. No complaints have been received by the Commission since the home changed ownership. The complaints procedure was clear and contained all the elements required including a written maximum response time of less than 28 days and details of how to contact the Commission. The home has a copy of the local Adult Protection procedure and all staff have received adult protection training. The home also has a Whistle Blowing Policy and an Abuse Policy. There is a Gifts Policy, a Restraints Policy, and the Wills Policy does indicate that staff are precluded from being involved in the making or being the beneficiary of a residents’ will as required under this Standard. The home does not handle any residents’ money and there are lockable spaces in residents’ rooms and a safe for secure holding of valuables. Rutland House Care Home DS0000068599.V352034.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): Standards 19, 25, and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not in the best condition but is being rapidly improved. This should create a pleasant environment that promotes the residents’ dignity and emotional well-being. Service users generally benefit from a safe and comfortable environment. Facilities are suitable and well maintained although thermostatic mixer valves are needed in at least one room to prevent scalding. The home is generally hygienic and clean, homely and comfortable except for some minor remaining odour problems in some areas. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home is not in the best condition but is being rapidly improved. This should create a pleasant environment that promotes the residents’ dignity and emotional well-being. Improvements to the environment included new furniture, a new fire alarm system, decoration of the downstairs, and current decorating of the upstairs. There was clear examples of regular and consistent improvements to the environment and substantial sums of money being made available for this. To be proportional and to reflect this a recommendation will only be set at this time as follows: The manager should continue with the planned improvements to the environment. Emergency alarms, fire responsive doors and a new fire alarm system are all present. Standard 25 requires thermostatic mixer valves to be fitted to all water outlets in homes of this type. Bedroom 1 on the ground floor did not have this device fitted. The following requirement is set under Standard 25 to address this: Thermostatic mixer valves must be fitted to all bedroom sink water supplies and any other water supplies the residents have access to. Specific policies were seen covering the disposal of clinical waste, use of cleaning materials, storage and preparation of food, use of protective clothing and dealing with spillages. Clinical waste is stored well away from the building. Hand washing facilities and protective clothing was observed to be available where required and used. The home was generally clean and hygienic, however some rooms had a slight odour of urine in them. The manager was aware of this and has been addressing it since taking over the home. The building was clean and carpets had also been cleaned. More drastic methods may be needed as it is possibly wooden floorboards that are the cause of this through a long term lack of hygiene before the home was taken over by the current owners. To be proportional and facilitate monitoring improvements in this area by the Commission, a recommendation only will be set at this time as follows: The home should explore methods of addressing the odour in some rooms. However, if this situation does not improve a requirement will then be made. Rutland House Care Home DS0000068599.V352034.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): Standards 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 numbers are of sufficient quantity to meet the residents’ needs and provide consistency. Staff are well trained with at least 50 or more staff with the NVQ2 qualification. Achieving this raises the quality of staff, their knowledge and their practices. The staff vetting procedure was to a high standard but records of this were not fully accessible. Addressing this will further protect the residents from undesirable staff. Induction and foundation training to National Training Organisation’s specifications needs to be in place. This should create a more highly trained workforce. EVIDENCE: Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 20 The home is managed and run on a day-to-day basis by the owner/manager, with assistance provided by staff. The lack of reportable incidents and quality of care indicate that staffing levels are currently appropriate. 50 of staff have the required NVQ2 qualification. This meets the current minimum of 50 of staff as required. Staff recruitment records are in place and were available for inspection. Records included Criminal Record Bureau checks, proof of identity, work permits and references. Although the residents’ files were in very good order, the staff files {particularly those relating to the previous employers} were in poor condition. Although no serious staff vetting concerns were identified, many documents were not easily found and some could not be found at all. The following requirement is set under Standard 29 to address this: All elements of Schedule 2 and 4 {staff files} must be kept securely on site and be available for inspection. Although an induction is provided, induction and foundation training to National Training Organisation’s specifications as required under Standard 30 was not in place. The following requirement is set to address this: All staff recruited since April 2002 must undertake a six weeks induction and six month foundation training to National training organisation’s specifications and targets. Rutland House Care Home DS0000068599.V352034.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): Standards 31, 33, 35, 36, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from continuity and a generally well run home. The home has implemented the quality assurance tools required, once it has provided an annual development plan that included residents and relatives quality issues, and feeds this back to them, this should ensure that the home is run in a way that involves the residents and a way that is in the best interests of the residents. Residents’ financial interests are safeguarded by the home’s policies, practice and lack of involvement by the home. Staff supervision meets the required frequency, this ensures a well supervised workforce. Health and safety policies and procedures do usually protect the residents. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 22 EVIDENCE: The owner manager runs the home and has provided evidence of consistently raising standards since taking over the home. The owner manager provides consistency and expertise to the residents and has a good relationship with them. The owner manager is a qualified nurse has many years direct experience in the field and has also completed the registered managers award. The home has all the required quality assurance tools, like a complaints system, audits and quality questionnaires for residents and relatives. These now need to be pulled together into a structured Quality Assurance system that makes the service users central to the process. An annual development plan drawn from the quality assurance tools, open to the residents, and meetings to feed this information back to them is needed to convert the tools into a system that meets Standard 33 fully. The following requirement is therefore set under Standard 33: The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home must also ensure that there is annual development plan that is open to the service users, to allow measurement of achievement in improving quality. This requirement will not affect the overall outcome for the group of standards on this occasion, for the following reasons: The quality assurance system is practically in place. One year is usually needed for quality assurance to conclude, and the home has not been running with the current owners for one year yet. The overall rating will therefore currently remain as good. The home does not manage any residents’ finances, or act on behalf of, service users. Formal recorded supervision to all care staff is provided at a rate of one session every six weeks. This meets the frequency required. This is provided to all care and nursing staff and includes practice, philosophy of care, and career development needs. Staff sign to confirm records. Other ancillary staff are supervised as part of the normal management process. Staff also receive an annual appraisal. All of the health and safety policies and procedures relevant to this Standard have been seen to be present. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 23 Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were available and these substances were all locked away. All of the procedures and testing of systems required in Standard 38 were also present. See Standard 25 for information regarding water temperatures. A number of the older doors in the home have a suspected asbestos product fitted to their backs as an old fashioned fire retardant measure. These types of products may cause damage to health and must be therefore sampled, then analysed to determine the type of asbestos if any, and then dealt with appropriately. Depending on the type of asbestos, labelled, sealed, or removed safely. The following requirement is set to address this: The suspected asbestos products lining the backs of the old doors in the home must all be sampled, checked and analysed to determine the type of asbestos and risk if any. Any identified product must be treated accordingly, e.g. left if safe, labelled to identify the type of product, and sealed, or removed as required in the identification and analysis report. This requirement will not affect the overall outcome for the group of standards on this occasion, for the following reasons: The substance identified has not yet been confirmed as asbestos. There has been no delay in responding to this requirement yet. All of the required annual checks are in place. The overall rating will therefore currently remain as good. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 x x x x x 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 2 Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 5 12[2] [3] Requirement The fact that front door is kept locked to protect the residents needs to be recorded clearly in the Statement Of Purpose and service users guide. This will ensure that all potential residents and relatives, and any placing care managers all know and agree to this restriction of liberty, before a placement is made. This will ensure that no residents are placed that do not need this restriction for their protection, and therefore that no unnecessary restrictions of liberty are placed on any resident. Thermostatic mixer valves must be fitted to all bedroom sink water supplies and any other water supplies the residents have access to. All elements of Schedule 2 and 4 {staff files} must be kept securely on site and be available for inspection. Timescale for action 01/01/08 2 OP25 12[1] 13[4]a 01/12/07 3 OP29 17[1][2] [3] 01/01/08 Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 26 4 OP33 24,1,2,3 The home must pull together its 01/04/08 Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home must also ensure that there is annual development plan that is open to the service users, to allow measurement of achievement in improving quality All staff must undertake a six 01/04/08 weeks induction and six month foundation training to National training organization’s specifications and targets. The suspected asbestos products 01/02/08 lining the backs of the old doors in the home must all be sampled, checked and analysed to determine the type of asbestos and risk if any. Any identified product must be treated accordingly, e.g. left if safe, labelled to identify the type of product, and sealed, or removed as required in the identification and analysis report. 5 OP30 18(1)a c 6 OP38 12[1] 13[4]a 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 OP26 OP19 Good Practice Recommendations The home should explore methods of addressing the odour in some rooms. The manager should continue with the planned improvements to the environment. Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Rutland House Care Home DS0000068599.V352034.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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