Inspection on 11/06/07 for Rutland Manor

This inspection was carried out on 11th June 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

Rutland Manor 02/06/08

Rutland Manor 10/07/06

Rutland Manor 16/01/06

Rutland Manor 02/11/04

Rutland Manor 27/05/04

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

CARE HOMES FOR OLDER PEOPLE Rutland Manor 99-109 Heanor Road Ilkeston Derbyshire DE7 8TA Lead Inspector Janet Morrow Key Unannounced Inspection 11th June 2007 10:30 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 Manor DS0000002162.V342947.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 Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rutland Manor Address 99-109 Heanor Road Ilkeston Derbyshire DE7 8TA 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) 0115 944 0322 01159 321793 Rutland Manor Limited Ann Kathleen Martin Care Home 41 Category(ies) of Dementia - over 65 years of age (41) registration, with number of places Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th July 2006 Brief Description of the Service: Rutland Manor is situated on the outskirts of Ilkeston. The building was previously a hospital. The accommodation is arranged on two floors with lounges and communal areas all being on the ground floor. Ongoing refurbishment is being undertaken to upgrade the accommodation. The home is registered as a care home with nursing for residents with dementia and can accommodate up to 41 residents. An activities co-ordinator is employed at the home and health professionals such as General Practitioner and chiropodist are accessed as required. Information provided by the service in May 2007 stated that the fees were in the range of £427 - £630 per week. Details of previous inspection reports can be found on the Commission for Social Care Inspection’s website: www.csci.org.uk Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over two days for a total of 10.5 hours. Two hours were spent observing the care given to residents in the lounge. The care of three people was looked at in depth when comparisons with the observations were made with the home’s records and the knowledge of the care staff. Care records and staff records were examined. Three members of staff, nine of thirty-six residents currently accommodated, one visiting professional and three relatives were spoken with. A partial tour of the premises was undertaken. Quality assurance surveys undertaken by the home were examined. Thirty-one residents’ surveys were returned to the Commission for Social Care Inspection prior to the visit but limited information was available on these due to residents’ communication needs. One visiting professional was contacted by telephone following the inspection visit. Written information supplied by the home informed the inspection process. Two recent adult protection enquiries were discussed with the manager. The final outcome of these was not known at the time of the inspection visit. One complaint received at the office of the Commission for Social Care Inspection since the last inspection in July 2006 was also discussed. An additional focussed visit had occurred in August 2006 to assess compliance with medication issues that were raised following the last inspection visit in July 2006. This visit found that medication procedures had improved and a monitoring system had been established to ensure standards were maintained. What the service does well: Rutland Manor has a number of staff who have worked at the home for several years, which helps to provide a stable and caring environment. All the residents who were able to express their opinion and relatives spoken to were pleased with the service provided. One relative described the home as ‘very good’. Residents’ individual interests and social history were well documented and there was encouragement to take part in a range of activities according to individual ability and interest. The observation showed that the majority of communication with residents demonstrated an understanding of individual needs and that respect and dignity was maintained. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 6 Residents enjoyed the meals provided by the home. The home was well managed and staff had good access to a range of relevant training courses, including National Vocational Qualifications (NVQ) training. Feedback from visiting professionals was particularly positive with comments such as ‘it’s an excellent place to be part of an extension of family life’ and ‘staff do a difficult job with remarkable resilience and good humour’. What has improved since the last inspection? What they could do better: Greater consistency was needed in ensuring medication administration record (MAR) charts were always fully completed with the amount of medication received. The temperature of the medicine storage room should also be monitored to ensure it does not exceed 25 degrees. This is necessary to ensure medicines are stored safely. Staff recruitment information must always account for gaps in employment to ensure that legal requirements are met. Care plans should include a specific risk assessment tool to identify those residents at risk of falling and help staff to provide intervention to prevent falls from occurring. All staff should be aware of the necessity of communicating with residents in a meaningful way and have knowledge of their social history and preferences. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 7 Those who have received training in specific techniques should be able to put this into practice. The statement of purpose and service user guide should be more specific about the type and amount of communal space available to enable a more informed choice about the home. 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 Manor DS0000002162.V342947.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 Manor DS0000002162.V342947.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, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was sufficient admission information to establish that the home was able to meet residents’ needs. EVIDENCE: The home’s statement of purpose had been amended and now contained all the information required by the Care Homes Regulations 2001. However, it could be further improved by giving more specific detail on the communal space available to residents. A service user guide was available that included all the necessary information to allow residents to make an informed choice. A sample contract was seen and contained the information required by the Care Homes Regulations 2001, which included a breakdown of fees for accommodation, personal care and nursing care. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 10 Four residents’ care records were examined and all had an admission assessment in place, and information from external professionals, where applicable. This information included risk assessments for nutrition and pressure sores as well as a general moving and handling assessment, plus a detailed social history and individual likes and dislikes. The information available established that the home was able to meet residents’ needs and relatives interviewed also confirmed that needs were well met. Written comments seen from a relative stated that residents were ‘so well looked after’ and a visiting professional spoken with stated that the home was ‘meeting needs’. Staff had completed specialist training in dementia in September 2006, which utilised observational techniques to fully assess individual needs. Rutland Manor DS0000002162.V342947.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. Health care needs were generally met but some inconsistencies in medication administration procedures needed improving to ensure residents were not put at risk. EVIDENCE: Care planning and assessment information was available in the four residents’ care files examined. Risks identified in assessment documentation were followed through into interventions to minimise the risks. For example, in the files examined, where a tissue viability risk assessment indicated a high risk of pressure sores, there was a care plan in place on how to deal with the risk and where a nutritional risk was indicated there was also a care plan to address the risk. Although mobility care plans addressed risk of falls, there was no specific risk assessment tool being used to indicate the level of need. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 12 Moving and handling assessments were in place on all the files seen and staff spoken with confirmed that they had received training in this area. An updated checklist on moving and handling arrangements was made available on a monthly basis and distributed to all staff to ensure that they were familiar with any changes to residents’ moving and handling arrangements. Those staff spoken with were familiar with this and found it a useful ‘at a glance’ check to track changes. Care planning information was thorough and gave sufficient information to know how care was to be carried out. The observation carried out looked specifically for indications of residents’ wellbeing and/or distress and type of staff interaction. During the period of observation, there was no evidence of residents’ being distressed and some staff were proactive in engaging with residents in a positive manner, such as offering newspapers and having a conversation. Requests for assistance were responded to promptly. However, some staff were less proactive and tended to observe residents’ rather than interact with them. A visiting professional spoken with also commented that they had observed a lack of interaction from some staff. Privacy and dignity was upheld and residents were observed to have warm relationships with staff. Relatives interviewed confirmed this and described the staff as ‘caring’ and a visiting professional spoken with also confirmed this, stating that residents’ were ‘treated as individuals and with respect’. The medication administration record (MAR) charts of eighteen residents were examined to check the accuracy of the recording. This showed that records were accurate, with signatures in place for medicines dispensed. There was a query raised regarding one chart that did not correspond with the blister pack; i.e. the medication being issued was in week four where all other charts were in week three. The nurse spoken with at the time did not have an explanation for this but the manager later explained that it was a result of new medication being ordered and dispensed on a different date. Two people were signing handwritten medication administration record (MAR) charts to ensure they were accurate but the amount of medication received into the home was not recorded consistently on all charts. Two residents’ MAR charts were then examined in more detail and were completed accurately. The nurse spoken with stated that Temazepam was stored and administered under controlled conditions and the records of Temazepam corresponded with the stock held. There were no controlled drugs currently in stock. Secure storage facilities were available. A general check on medicine stocks was carried out and found to be satisfactory with no medicines being past their expiry date. Eye drops were stored in the medication refrigerator and labelled with date of opening. The Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 13 refrigerator temperatures were recorded on a daily basis (although there were occasional dates when this had not occurred) and found to be within safe limits. The temperature of the storage room was discussed with the manager and nurse and although within safe limits at the time of the visit, it was unclear whether a safe temperature (i.e. not above 25 degrees) was maintained during hot weather. The manager was undertaking regular monitoring of recording on MAR charts and a new audit tool was about to be put into practice to assist with this. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Meals, activities and contact with the community were well-organised and enhanced residents’ daily lives. EVIDENCE: The home had an activities co-ordinator who organised a range of events to entertain and motivate residents. Both residents and their relatives interviewed confirmed that that the routines of the home were flexible and it was observed that residents’ had the choice of whether or not to participate in activities. Detailed information was maintained on residents’ past history and likes and dislikes, which were incorporated into their social care plan. The observation showed that a range of options were available to residents; for example, staff were observed chatting with residents, looking at newspapers and playing dominoes with them, some residents were pursuing their own hobbies such as reading, one was enjoying listening to music and they were also being assisted to see the hairdresser. They were also being offered hand Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 15 massages on the second day of the inspection visit. Staff spoken with were knowledgeable about individuals’ routines and knew which residents preferred to be left sleeping in the morning and who were more active at different times of day. For example, one resident who appeared mostly withdrawn during the observation was more active and moving around the building on the second day and staff stated that some residents who walked a lot on one day tended to rest and sleep on the following day. However, the observation also showed that the more vocal and active residents were the ones who received most attention. Those who appeared withdrawn were not offered any stimulation during the observation period and one resident spoken with said they were ‘bored’. Religious ministers from the local area visited the home on a regular basis and outings occurred in the summer weather. Photographs of a trip to Nottingham Castle in 2006 were on display. Those relatives spoken with confirmed that they were made to feel welcome at any time and were able to visit when they wished. One relative praised the Easter celebration that they had been invited to attend. The manager was aware of who to contact for an advocacy service and there was written information about this in the home’s service user guide. Most information was in written format but there were plans to produce more pictorial information to aid understanding. Those residents spoken with also said they enjoyed their meals and stated that they were offered alternatives if they did not like what was on offer. Staff spoken with were aware of individual likes and dislikes and were able to discuss various strategies to ensure that residents ate a balanced diet. The written information supplied by the home included sample menus that showed meals were wholesome and nutritious. The serving of the lunchtime meal was observed and demonstrated that individual preferences were taken into account. The dining area was bright and cheerful. The mealtime was unhurried, with appropriate assistance being given to those residents who needed help with eating. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure that complaints and adult protection issues were responded to appropriately, which ensured that residents were protected and their concerns handled objectively. EVIDENCE: The complaints procedure was examined and this showed that complaints would be dealt with in twenty-eight days. There were plans to introduce a pictorial version of the procedure to aid understanding. The written information supplied by the home stated that there had been no complaints received at the home since the last inspection in July 2006. One complaint had been received at the office of the Commission for Social Care Inspection and had been referred to the provider for investigation. A full response had been received that addressed the issues raised. Those relatives spoken with were aware of how to make a complaint and were confident of a courteous response. Adult protection procedures were in place and the written information supplied by the home stated that staff had attended training in dealing with abuse in September 2006 and April 2007. Those staff interviewed were aware of their Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 17 responsibilities in reporting suspicions of abuse. The home also had the full documentation of Derby and Derbyshire Local Authority Social Services procedures. The manager was familiar with reporting procedures and how to refer to the Protection of Vulnerable Adults (POVA) list. Two allegations had been investigated via adult protection procedures and both had been dealt with appropriately. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 18 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 building was clean and tidy and provided safe, comfortable accommodation for residents. EVIDENCE: A partial tour of the building showed that the home was clean, tidy and odour free at the time of this inspection visit. A new staff room had been completed. The external garden area was neat and tidy. The written information supplied by the home stated that some refurbishment of seven bedrooms had taken place with decoration and new furniture being provided. Individual alarms for bedrooms to alert staff to residents getting out Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 19 of bed had been purchased for those at risk of falling and two new beds had been purchased. The manager also stated that it was planned to purchase new dining room furniture. The laundry was viewed and was neat and tidy and all equipment was in working order. Staff spoken with were aware of how to control the spread of infection and confirmed that there was always a plentiful supply of protective equipment such as gloves and aprons. They confirmed that they had received training in this area. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 20 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. There were sufficient qualified staff deployed, which ensured that residents’ care needs were met. Recruitment procedures were robust, which ensured that residents were protected. EVIDENCE: The written information supplied by the home included staff rotas for the period 2nd –29th April 2007 for trained staff and March 5th – April 8th 2007 for care staff. This showed that there were two nurses on duty on the daytime shifts and one nurse at night and there were also five care staff on the morning shift and four on the afternoon shift. The manager stated that this number changed depending on the number of residents and their needs and on the day of the inspection visit there were six care staff on the morning shift. There were also supernumerary staff on placement as part of their training course. The manager stated that there were no issues currently with staffing and the staff group was stable, although there was a vacancy for a deputy manager. Agency staff were used infrequently. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 21 Staff spoken with praised the access to training and stated that they had a range of options open to them. The written information supplied by the home also stated that additional training on subjects relevant to the home such as dementia, diabetes, palliative care and continence also took place. Senior staff had undertaken a specialist course in September 2006 to study a particular method of working with people with dementia. However, staff spoken with stated that they had not had the opportunity to fully put this in to practice as it was a time consuming method. Staff files showed that induction training for new starters took place, with staff signing to say they had completed the programme. The home was committed to National Vocational Qualifications (NVQ) training and the written information supplied by the home stated that eleven of eighteen care staff had achieved an NVQ level 2, which was approximately 70 of the care staff. A further four were due to finish the NVQ Level 3 training in the next two weeks. This ensured that the standard of having 50 of care staff qualified to NVQ level 2 was exceeded and the home is therefore commended for its commitment to NVQ training. Three staff files were examined and showed evidence of good recruitment processes. Most of the documentation required by Schedule 2 of the Care Homes Regulations 2001 was in place, including a Criminal Record Bureau check, evidence of identity and qualification and two written references. Protection of Vulnerable Adults (POVA) checks were in place and showed that these were obtained prior to a member of staff commencing work in the home. However, the application forms on two files were not completed sufficiently to show gaps in employment and reasons for gaps, although the administrator later confirmed that one member of staff had provided a full c.v. shortly after the inspection visit. Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 22 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 home was well managed and health and safety needs were addressed which ensured that residents’ interests were safeguarded. EVIDENCE: The manager was a trained nurse, had completed the Registered Managers Award and had several years experience in caring for older people. A visiting professional stated that she set a ‘good example’ for staff. The owner had appointed a ‘compliance’ manager for the company who was involved in Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 23 dealing with complaints and quality assurance and was actively looking at ways to improve the service. A quality assurance plan was in place and was involved looking at all aspects of the service, for example producing better information for residents in a variety of formats, responding to complaints and acting on the findings and producing audit tools to monitor the quality of the service. The manager was proactive in obtaining the views of visiting professionals and recent comments received in May 2007 were positive, such as: • ‘Never had to cause to complain’ • ‘A calm and peaceful environment’ • ‘Appear to place residents care needs first’ A relatives’ survey seen also responded that the environment, quality of nursing and co-operation of staff were all ‘excellent’. Three residents’ financial records were examined and were completed accurately, with receipts being available for identified purchases. Cash was stored securely. A valid insurance certificate and registration certificate were on display. Staff training records and the written information supplied by the home indicated that training had been undertaken in mandatory health and safety subjects such as first aid, moving and handling, food hygiene and fire safety. The written information also stated that regular maintenance of equipment took place that included fire equipment in January 2007, water safety in November 2006, emergency lighting in January 2007 and the call system in January 2007. Hoists were being checked during the second day of this inspection visit. A random check of records showed that gas safety was checked in November 2006 and that portable electrical appliances were tested in June 2006. Accident records were available and also included a monthly audit of how many accidents had occurred. Rutland Manor DS0000002162.V342947.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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Rutland Manor DS0000002162.V342947.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 OP29 Regulation 19 (1) (b) (i) Schedule 2 Requirement Recruitment information must identify gaps in employment and the reason for gaps must be explained prior to staff commencing employment in order to fully meet the requirements of Schedule 2 of the Care Homes Regulations 2001. Timescale for action 01/08/07 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. 3. Refer to Standard OP1 OP7 OP8 & OP12 Rutland Manor Good Practice Recommendations The statement of purpose should detail the amount and type of communal space available to residents. A specific risk assessment tool should be used to identify residents who are at risk of falling. All staff should endeavour to interact positively with residents, particularly those who appear more withdrawn. DS0000002162.V342947.R01.S.doc Version 5.2 Page 26 4. 5. OP9 OP9 The temperature of the medicine storage room should be monitored to ensure it does not rise above 25 degrees. Medication received into the home should be recorded consistently on all medication administration record (MAR) charts. Fixed screening around bed and sink should be provided in shared rooms. This is a previous recommendation and was not assessed on this occasion. Those staff who are trained in specialist techniques should be given time to put this into practice. 6. OP24 7. OP30 Rutland Manor DS0000002162.V342947.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Manor DS0000002162.V342947.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. 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!