Inspection on 23/05/06 for The Roan Rest Home

This inspection was carried out on 23rd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Roan Rest Home 27/06/08

The Roan Rest Home 02/07/07

The Roan Rest Home 22/11/05

The Roan Rest Home 08/06/05

The Roan Rest Home 13/10/04

The Roan Rest Home 25/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Roan Rest Home 27/29 Pembroke Crescent Hove East Sussex BN3 5DF Lead Inspector Mike Flint Key Unannounced Inspection 23rd May 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 The Roan Rest Home DS0000014253.V295081.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. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Roan Rest Home Address 27/29 Pembroke Crescent Hove East Sussex BN3 5DF 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) 01273 772927 01273 738260 Mr Joginder Singh Vig Mrs Beant Kaur Vig Mrs Beant Kaur Vig Mr Balbir Roy Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is nineteen (19) Service users must be older people aged sixty-five (65) years or over on admission 22nd November 2005 Date of last inspection Brief Description of the Service: The Roan Rest Home is a residential care home providing social and personal care for up to nineteen older people. The home is one of several care homes in the Hove area, owned by Mr and Mrs Vig. The Roan Rest Home is situated in a residential area of Hove, within close walking distance of local shops, a library and nearby transport links. Accommodation is provided over three floors in a large property that has been converted from two houses. A passenger lift enables residents to access all parts of the home. However, there is a short flight of stairs to mezzanine levels that place some limitations on residents with restricted mobility i.e. the home would not be suitable for wheelchair users. The home provides seventeen single rooms, eleven of which are en-suite, and one registered as a double room, though this is used for single occupancy. There is a spacious communal lounge/dining area on the ground floor, and a quiet lounge for residents and visitors, on the first floor. There is a small, walled garden, with access for residents, at the rear of the building. The home is jointly managed by Mrs Vig and Mr Balbir Roy. Fees at the home currently range from £298.70 to £403.00 per week. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of the home was carried out over seven and a half hours, during a day in mid May, when there were 18 residents, one of who was at The Roan for a respite stay. On the morning of the visit there were four care staff, who between them were covering also some cleaning duties and cooking, in the absence of the employed cook, due to holiday leave. The deputy manager, Denise O’Brien and the registered manager, Mrs Vig were also present and able to assist throughout the day with the inspection. In the afternoon there were two duty carers and an activities co-ordinator. The duty rotas inspected showed that satisfactory staffing levels are maintained during the waking day, from 7.00 a.m. to 9.00 p.m., with one waking night duty and on-call arrangements. As part of the inspection process and prior to this site visit, the Inspector received eight responses to a postal survey questionnaire from residents and/ or their relatives. A further four were completed and returned by General Practitioners, who have known the home. Additional information was gathered during telephone calls to residents’ family members and from visiting professionals from the Community Healthcare teams. During the inspection the Inspector joined residents for the lunchtime meal and afterwards spoke with five of the residents in private. Duty staff were also spoken with in private. A pre-inspection questionnaire, giving current information about the home, had been completed by the senior carer and returned to the Inspector some weeks before the unannounced site visit. What the service does well: What has improved since the last inspection? There has been a positive response by the home to the significant number of requirements and recommendations, made at the time of the last inspection, carried out in November 2005; an action plan was subsequently received and checked during this inspection, showing that most of the areas identified for The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 6 improvement have now been addressed. Furthermore and shortly before this inspection, the Commission’s Pharmacy Inspector conducted an inspection, when several requirements were made, concerning the administration of medicines within the home; each of these was checked also and found to have been satisfactorily addressed. A suitably documented system of care planning and risk assessment is now in place that ensures continuity of care for each resident, some of whom have key workers, depending on individual circumstances and level of need. Personal profiles have been recorded that provide staff with helpful information about each resident’s history. The deputy manager indicated that further improvements to the home’s care planning methodology are on-going. What they could do better: At the time of the inspection there were no staff working towards the required NVQ training awards in Care, though the Inspector was told that suitable funding arrangements are now in place for five of the carers to start this training later in the year. At that time also the deputy manager is to commence the NVQ training for care home managers. In the meantime it is recommended that training for all staff is to include falls prevention and the protection of vulnerable adults/ adult abuse. The home has a staff-training programme, which should be included as one aspect of the annual development plan for the home that has yet to be produced. This, being a required quality assurance measure, based on the home’s short, medium and longer-term aims and enables a review of the home’s performance in meeting these and the outcomes for residents, they affect. Evidence suggested that off duty staff are not being reimbursed on occasions, when they come in for training purposes on their days off; that formal supervisions are not in place for all care staff; and that, at times, staff shortages have placed disproportionate responsibilities on care assistants. A greater emphasis on staff training and support is required. The Inspector thanks the owner/ manager, Mrs Vig, the deputy manager, the staff and the residents for their participation, co-operation and hospitality shown during the course of the inspection. Thanks also to those others, who have contributed their comments, as part of this inspection of The Roan Rest 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 Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 7 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 The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good; people who are referred to the home are fully assessed enabling decisions to be taken in respect of the home’s ability to meet the individual’s needs, prior to accepting admissions. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A suitably detailed and well presented Statement of Purpose and Service User Guide is available to prospective, or newly admitted residents to inform them about the home and of the services and facilities that are to be provided. There is also an illustrated leaflet produced. All residents receive a copy of the Terms and Conditions of their residency in the form of a contract; having discussed the content of this document with the manager and residents, the Inspector recommended that the home’s policies on smoking, drinking and pets be included within the terms and conditions, once agreed. Pre-admission assessments are completed for all potential users of the service, referred to the home, prior to a trial period being offered; samples of these The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 9 were shown to the Inspector. The manager said that either she or her deputy would be responsible for carrying out these initial visits, be they to home or hospital. In the case of funded placements, the Local Authority provides health or social care assessments. Visits to The Roan are arranged, wherever possible, to assist people in reaching a decision about whether to move in for a trial period. Each of the residents spoken with was able to confirm that they felt their needs were being met at the home. Comments from relatives spoken with included, ‘…never seen her so happy….’, ‘…..have nothing but praise for the home.…’ and ‘……the care there is excellent……’. As a measure to ensure that residents’ needs are being met at all times, especially those with deteriorating conditions, staffing levels at the home are required to be kept under review, including night shifts, when there is currently one waking night staff and an on-call manager. The manager stated that there have been occasions when a second, night duty staff has been employed. Day staff spoken with said that they would sometimes cover a night shift, in case of illness or holiday absences. The home does not offer intermediate care, or rehabilitation services, though does provide for short-term respite stays, when there is a room available. The Inspector spoke with a gentleman who was receiving respite care and was told that ‘….the staff here are very good….’. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in these outcome areas is good; personal support at The Roan Rest Home is offered in such a way as to promote and protect the residents’ privacy, dignity and independence. Care planning documentation provides sufficient information for staff to ensure continuity of care. These judgements have been made using available evidence including a visit to the service. EVIDENCE: A satisfactory system of care planning and risk assessment is being used; the deputy manager said that these were to be further developed e.g. by including a photograph of the resident for the benefit of new, or agency staff. The Inspector recommended that more detailed information could be shown in the risk assessments, particularly in the case of those residents who are prone to falls, or those suffering with confusion, who may wander. One resident, who had been assessed earlier in the year, was awaiting a vacancy to become available in a nursing home for people with dementia; in speaking with the healthcare worker concerned, the Inspector was informed that until a bed became vacant she would stay at The Roan. In meeting residents and from an examination of case notes it was clear that a small number of residents were also showing signs of deteriorating mental health. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 11 Daily progress notes are used and the care plans are kept regularly updated with a monthly review; each care plan includes a helpful personal history of the individual concerned. A relative spoken with commented that she had ‘nothing but praise for the home’ and another said ‘the care provided is excellent’. The administration of medicines in the home appears to be satisfactorily managed. Since a recent visit by the Pharmacy Inspector, recommendations made at the time, regarding a number of ways in which procedures could be improved, have been acted on, including agreement as to a preferable, secure location for the medications trolley. The deputy manager confirmed that only the five staff, who have undertaken training, have responsibility for dispensing; certificates to this effect were seen to be kept in the staff files; she said that other staff were soon to receive this training. Residents may manage their own medicines, subject to risk assessment, having a lockable facility in their rooms for this purpose; at the time of the inspection, only the person admitted for respite stay had retained this responsibility; this resident told the Inspector that he was satisfied with his room and with the care he received. Staff seen in the course of their duties, were courteous and respectful towards the residents. Appropriate measures are taken by the home to ensure privacy e.g. by respecting residents’ choice as to whether they wished to socialise, or remain in their own rooms, with meals brought in to them. The Inspector observed that staff would always knock first on residents’ doors, before seeking entry and that they would respond attentively to the call bell system, located in all residents private rooms. At the time of the inspection the one double room was being used for single occupancy and the manager said that this would continue to be the case. Residents’ wishes concerning terminal care and arrangements after death are discussed at an appropriate time; records of such information were seen to be included in residents’ care plans. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good; mealtimes and communal activities are well managed providing interest and social opportunities for those living in the home. The home encourages family visits for the enjoyment and emotional well-being of residents. These judgements have been made using available evidence including a visit to the service. EVIDENCE: The home encourages residents’ participation in a variety of daily activities, details of which are posted up. The Inspector spoke with the activities organiser, who is employed on two afternoons each week; he confirmed that there was a good response from residents, who attended the group activities and that some time was set aside for individual activities. This was born out on the afternoon of the inspection, when eight of the residents were playing bingo and card games, whilst others were enjoying an old film on the TV. One resident told the Inspector that she enjoyed life at the home; a relative said about her mother ‘I’ve never seen her so happy’. It was clear to the Inspector that considerable efforts are made to introduce activities to residents and that they are consulted with about their interests. Some of the residents spoken with expressed their reluctance to join in, preferring to remain in their private rooms; one commented that she appreciated that staff respected that this was her choice and that she had never been much of one for socialising. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 13 Residents can have visitors as and when they wish; their choice of which they wish to see is respected. Each of the relatives spoken with said they were always made to feel welcome, when visiting the home and that staff were friendly. A hairdresser provides this service at the home on several days in the week and a chiropodist attends to residents on a regular basis. Residents who smoke are encouraged to go outside, weather allowing. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in these outcome areas is adequate; matters of concern are handled appropriately, reassuring those involved that they are being listened to and that action will be taken, as necessary. In response to the deteriorating mental health needs amongst some of the residents, staff are receiving training in dealing with this more challenging aspect of their work. All staff, currently working at the home, have been Police checked reducing any potential risks to residents’ safety and well-being. These judgements have been made using available evidence including a visit to the service. EVIDENCE: The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 15 There has been one complaint since the last inspection that was investigated by Social Services and later brought to the attention of the home’s Inspector. The complainant was an ex-resident of The Roan, who had moved to a home for people with dementia-type illnesses, before raising the matter with her social worker, saying she was scared to voice concerns about The Roan Rest Home while she was still a resident. The manager at The Roan stated that she had not been made aware of a complaint being made. There was no record of the complaint at the home. From information provided by the social worker concerned, there was some evidence to support the view that a resident, who presented with challenging needs, had not always been responded to appropriately by management and staff at The Roan, which, in the circumstances, and although not registered to provide for persons in that category, has taken responsible action in arranging for staff to receive training in dementia care. The social worker offered that meeting the needs of a resident, who exhibited such high levels of anxiety and phobia, as was the case in this instance, presented difficulties for carers. The home’s written procedure advising residents, or visitors to the home how to make a complaint is clearly shown in the Statement of Purpose and the terms and conditions for residents. Residents spoken with said that they found the staff and manager were approachable and responsive, should issues arise that required action. There are policies and procedures in place relating to adult protection and abuse, though no evidence to show that staff are receiving training in this area of their work, this being a mandatory requirement. The Inspector was shown that satisfactory Police checks had been completed for all staff. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good; the home provides a pleasant environment that is accessible and satisfactorily maintained, meeting residents’ individual and collective needs in a comfortable, homely style. These judgements have been made using available evidence including a visit to the service. EVIDENCE: The layout and location of the home is suited for its purpose and well maintained by the joint manager, assisted by an employed handyman. There is a small, private rear garden, which is attractively maintained and safe for use by residents, weather permitting. Within the home, there is a choice of communal seating areas that are comfortably furnished and pleasantly decorated, including a quiet lounge on the first floor and a large lounge/ diner on the ground floor. Each of the residents’ private rooms, visited by the Inspector, appeared to be furnished and decorated to a satisfactory standard. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 17 The overall standard of cleanliness in the home appeared to be good and there were no unpleasant odours; the home employs a cleaner on four days each week and care staff assist with this task on the other days. Arrangements are in place for the safety of the few residents who are smokers. A fire risk assessment for the building has been carried out very recently by a contract Fire Protection service, with a Certificate of Competence issued on 17 May 2006. The handyman records routine checks of the fire safety equipment, including alarms and emergency lighting. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good; a competent and well-motivated staff team meets residents’ personal care needs, though levels of the required NVQ qualification amongst care staff need addressing. These judgements have been made using available evidence including a visit to the service. EVIDENCE: Duty rotas submitted prior to the site visit showed satisfactory day-time staffing arrangements, with three care assistants rostered from 7.00 a.m. to 9.00 p.m. and one waking night staff and an on-call manager, or senior, who live nearby; the owner/ manager said that an additional waking night, or a sleep-in duty has been employed on occasions when the need has arisen, due to increased levels of need. The Inspector remains un-reassured that these arrangements ensure the safety and well being of this group of vulnerable residents, some of who present as being mentally and physically frail; it is therefore required that the night staffing arrangements be subject to constant review. A cook is employed and there is an ancillary worker for cleaning. Comments from staff, received since the inspection visit, indicate that staff vacancies, or due to sickness, sometimes long weeks are worked, without sufficient time off and that shift patterns frequently change during the week, for the same reasons. At the time of this inspection there were no care assistants undertaking NVQ training, though the Inspector was told that funding for five training places had been secured for later in the year. The owner/ manager produced a detailed record of staff training already undertaken. An examination of staff files The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 19 showed that all new staff training in all safe working elderly, including dementia 12 months. Staff files were receive induction. Records showed also that basic practices and topics associated with the care of the care has been provided for care staff within the last inspected and found to be in satisfactory order. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is good; the owner/manager is a competent manager, though is not qualified in this area and therefore does not meet the required Standard. Health and safety checks are not being carried out and recorded on a regular basis that would contribute significantly to the safety and welfare of residents. These judgements have been made using available evidence including a visit to the service. EVIDENCE: The owner/ manager has a nursing qualification and is very experienced in the management of residential care services over many years. However, there is a lack of recognised management qualification and the Inspector was informed that the deputy manager is to commence the required training, the NVQ 4 and Registered Managers Award, later this year, before application is made to register her as manager for The Roan. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 21 Many of the required quality assurance measures have been put in place since the last inspection, including residents’ satisfaction questionnaires, staff supervision (though not yet for all staff) and training in safe working practices. The home has yet to produce an annual development plan as evidence of satisfactory forward planning and performance review. Comments received from staff, since the inspection site visit, suggest that not all staff have job description, or receive formal supervision. One commented that more staff meetings and support from senior staff would be found helpful as sometimes there are just two care assistants, left to care for all the residents. Although the co-manager, responsible for maintenance in the home, keeps a record of tasks requiring attention, there is no formalised health and safety check currently being carried out and recorded for all areas of the premises to which residents have access. Neither is there a fire safety policy implemented in respect of residents’ doors being kept open, at their request; this includes night times also, when all fire doors should be checked as closed. Additionally there should be a record made on individual care plans in respect of those residents, who do not wish to be routinely checked on by night staff. The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 22 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 2 3 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 3 2 The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 01 Standard OP4 Regulation 18(1)(a) Requirement That night staffing arrangements are kept under review to ensure at all times there are sufficient numbers of duty staff, on the premises, to ensure any changes in the healthcare needs of residents are satisfactorily met. That all care staff receive training in falls prevention and in the protection of vulnerable adults/ adult abuse. That the home achieves the 50 target of staff trained to NVQ at level 2 and/ or 3 in Care. That all staff receive a minimum of three paid days training per year (including in-house training). That the manager undertakes a recognised course in management i.e. the City and Guilds Registered Managers Award, or that plans are implemented to employ a manager, who is qualified with DS0000014253.V295081.R01.S.doc Timescale for action 01/07/06 02 OP18 13(4)(c) 01/10/06 03 OP30 18(1) 01/05/07 04 OP30 18(1) 01/07/06 05 OP31 9(2)(b)(i) 01/09/06 The Roan Rest Home Version 5.2 Page 24 the requisite management qualification and who is suitable for registration as the home’s manager. (Previous timescale unmet) 06 OP33 24(1)(a) & (b) That as an additional quality assurance measure an annual development plan is produced, based on a system if planningaction-review, reflecting aims and outcomes for residents. That all staff receive formal supervision and that care assistants are adequately supported by senior staff at all times. That the ‘required’ records be kept in the home, including an up to date edition of the National Minimum Standards for Care Homes for Older People, with Care Homes Regulations appendix, which refers. That a policy is implemented to ensure, so far as is reasonably practicable, any unnecessary risks to residents in the event of fire are eliminated, in particular respect of those residents who wish to have the door to their private room open, during their waking hours. 01/10/06 07 OP36 18(2) 01/07/06 08 OP37 17(1-3) 01/07/06 09 OP38 13(4)(a) & (c) 01/07/06 10 OP38 13(4)(c) & That environmental health and safety checks are routinely 23(2)(o) carried out and recorded for all areas to which residents have access, including the garden. 01/07/06 The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 01 Refer to Standard OP2 Good Practice Recommendations That the residents contract, showing Terms and Conditions of residency, is revised to include certain of the home’s policy statements that residents should be signing their agreement to e.g. smoking, drinking and pets. That the process of risk assessing be reviewed, particularly in the case of residents who suffer from confusion, or who are at risk from falls. That records are kept of the night-time checks, carried out by duty staff to ensure the safety and well being of residents, giving the time and status, relating to all such checks. That the lockable trolley, used for storing and dispensing medicines, is moved out of the main corridor, used by residents accessing the communal lounge/ dining area, to a more practical location, where it may be appropriately secured. That staffing levels in the home are maintained at levels satisfactory in meeting the residents’ needs at all times and that such arrangements are kept under constant review. That policies and procedures are regularly reviewed and amended as required to ensure that they contain information, advice and guidance for staff that is relevant to working practices within the home. 02 OP3 03 OP8 04 OP9 05 OP27 06 OP33 The Roan Rest Home DS0000014253.V295081.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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