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Inspection on 01/10/07 for The Rosary Nursing Home

Also see our care home review for The Rosary Nursing Home for more information

This inspection was carried out on 1st 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The people using the service were all complementary about the staff, commenting on their kindness and attention to detail. The inspector observed good interaction between people using the service and staff and people were noted to be treated with dignity and respect. One comment received was "The Rosary allows residents to maintain dignity and respect, motivates residents when they are feeling down, provides a laugh, good care, good food and accommodates family occasions very well". The activities provided were varied and involved the people using the service and staff in the choices of activity. On the second day of inspection a multicultural day was taking place to celebrate the diversity of cultures of the staff and people using the service. This involved a selection of cultural foods and demonstrations by staff of dancing from their country of origin. The management of people with nursing interventions appears well managed with the supporting involvement of visiting healthcare professionals. The manager designate had a positive leadership style, which reflects on the staff who feel supported by the management of the home. People using the service spoken with, all confirmed that the quality, quantity and variety of food is always good, there was evidence that individual preferences are catered for. Visitors spoken with confirmed that they were always made welcome and were kept updated with changes in their relative`s condition and were involved in the care planning process.

What has improved since the last inspection?

Since the previous key inspection the home has changed the way of displaying menus, they now have table top menus and white broads in each lounge which also displays the activties of the day. The home have increased care staff input into activities The home have purchased a gazebo so that people using the service can go outside more often. The home has undertaken an audit of Dementia Care Standards and developed action plans which are ongoing for people using the service who may have dementia care needs . The upstairs corridoor carpets have been replaced and maintenance remains ongoing.

What the care home could do better:

No requirements were made as a result of this inspection and 5 good practice recommendations have been made.

CARE HOMES FOR OLDER PEOPLE The Rosary Nursing Home Mayfield Drive Durleigh Bridgwater Somerset TA6 7JQ Lead Inspector Gail Richardson Unannounced Inspection 09:30 1 October 2007 st 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 Rosary Nursing Home DS0000061580.V349137.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 Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Rosary Nursing Home Address Mayfield Drive Durleigh Bridgwater Somerset TA6 7JQ 01278 431164 01278 446739 ltaly(rosarycarehome)@sanctuary-housing.co.uk 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) Sanctuary Care Limited Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63) of places The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to three persons for Respite Care for people aged 45 - 64 years, for a period of up to 28 days To provide care for two named persons, under the age of 65 years, with learning difficulties as per variation registration 22/05/06. To provide care for one named person, under the age of 65 years, with learning difficulties as per variation dated 17/08/06. Date of last inspection Brief Description of the Service: The Rosary Nursing Home is located on the outskirts of Bridgwater. It is owned by Sanctuary Care Ltd. It was purpose built in 1994 as a Nursing Home. The home is registered as a Care Home with Nursing (N), to accommodate up to a total of 63 persons. There are sixty-one single bedrooms and one double bedroom. One bed provides regular respite care. All, except three bedrooms, have an en suite facility, which includes a wash hand basin and toilet, two of these rooms have a shared facility and one a bathroom is adjacent to the bedroom. The home has wide corridors and two lifts, one eightperson/ 630Kg and one four-person/ 300Kg, which allow easy access to the first floor where twenty-six bedrooms are situated. Health and safety measures include window restrictors on the first floor, low surface temperature radiators and hold open devices on bedroom doors. Hot water is also restricted at the bath outlets. The home has been suitably adapted for the current resident client group, older persons requiring general nursing care. There is a high standard of decoration and furnishing. All bedrooms are fitted with telephone sockets. There is a Registered Nurse on duty at all times. The current fee range is £525.00 to £585.00 This does not include toiletries, chiropody and newspapers The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 2 days (10.5 hours) on the 1st and 2nd of October 2007 by inspector Gail Richardson. A tour of the home took place and a selection of bedrooms and all communal areas were seen. There were 62 people using the service currently residing at the home. 5 people using the service were receiving personal care only and the remaining number were all receiving nursing care. One person was receiving short term respite care and although the home does have a day care facility, no people using day care were present at inspection. The inspectors spoke to 9 residents, 2 visitors, and 10 members of staff, the acting manager was available throughout the inspection. All people using the service spoken to, and who were able, spoke of the staffs kindness, everybody stated that they were happy with the care they received. The inspectors spent time talking to people using the service, visitors and staff and observed that on the day of inspection, people using the service appeared relaxed and comfortable in all areas of the home and the atmosphere was settled and happy. There is an established, well-trained staff team and surveys from staff stated they felt supported by the management of the home. Records relating to care including 6 care plans, staff files, finances and health and safety records were examined. As part of this inspection the inspectors surveyed the opinions of a random selection of residents and their representatives, GP’s, District Nurses and Care Workers, a very good response was received and their comments will be included in this report. The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the previous key inspection the home has changed the way of displaying menus, they now have table top menus and white broads in each lounge which also displays the activties of the day. The home have increased care staff input into activities The home have purchased a gazebo so that people using the service can go outside more often. The home has undertaken an audit of Dementia Care Standards and developed action plans which are ongoing for people using the service who may have dementia care needs . The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 7 The upstairs corridoor carpets have been replaced and maintenance remains ongoing. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Rosary Nursing Home DS0000061580.V349137.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 The Rosary Nursing Home DS0000061580.V349137.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 4 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to be able to provide prospective residents and relatives with sufficient information in the format of brochures, the Service User Guide and Statement of Purpose for them to make an informed decision about the home. All prospective residents receive a pre admission assessment by the registered manager to ensure the home can meet the assessed needs identified. EVIDENCE: The homes AQAA states that We provide written information in the form of brochures , statement of purpose, service user guide. We invite all families to visit, with where appropriate, the service user where we respond to their individual queries and gain information about their needs, where indicated we offer them the chance to meet our currant services users to ask them their opinion of the home so The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 10 they can make the decision about the homes suitability. Discussion with people using the service and examination of the Statement of Purpose and Service User Guide confirmed that this was the case. All people using the service are provided with a contract to which they agree, this clearly states what services are offered and charges involved. This contract is available in large print. 10 Residents surveys received stated that all 8 had received a contract and all felt they had received enough information prior to admission, to make an informed decision about the home. 9 relatives surveys were returned to the inspector and of these confirmed that prior to admission 4 always received enough information and 3 said usually. The Rosary Nursing Home DS0000061580.V349137.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 10 11Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has a care plan, the assessed areas of need were reflected in this plan of care and the detail recorded ensures that staff can provide a good standard of care. The management of medications systems meets the required standard. Staff were observed to treat service users with dignity and respect at all times and residents fell well cared for. People who require end of life care receive care which is constantly reassessed to meet all changes in need and supports both the person and their relatives in the last stages of life. EVIDENCE: All people using the service have an individual care plan which is developed by a designated named nurse. The plan is initially based on the pre-assessment The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 12 findings and details specific interventions to manage all the needs of the person using the service both emotionally and physically. Further development of the care plan is done with the people using the service and/or families. The inspector case tracked 4 people from pre-admission to care planning and included documents relating to medication, accidents and finances. A further two care plans provided details of end of life care given. The care plans seen were of a good standard and provided staff with the details of identified risks and made a plan of care to meet these risks. It was discussed with the manager that not all people using the service had night care plans and one other area of identified need relating to sub cutaneous fluid infusion did not have a protocol contained in the care plan for staff to refer to. The acting manager is recommended to ensure that staff have access to this protocol to support their practice. Some aspects of these care plans were of a particularly high standard, including psychological and social care plans, night care plans and plans relating to specific nursing interventions. These were written in a clear and concise manner, which was supported by a good underpinning knowledge of resident’s choices and needs. The inspector observed this care taking place and examined the records maintained relating to the specific nursing interventions. Residents and relatives were involved in monthly care plan reviews and one care plan was signed by the person receiving the care. One relative confirmed that they were regularly involved in the planning of care for their relative and one relative commented “Communication between the staff and myself is excellent I am kept fully aware of matters to her health and well being.” A care plan was examined of a person using the service who had recently died. The plan of care had been regularly updated to meet the changing needs of the service user and all care given had been documented. There was evidence of regular contact with the relatives and their input in the plan of care. When asked do you receive the care and support you need, 6 surveys said always and 4 said usually and 1 said sometimes, 10 responded that staff listen and act on what the residents say and 1 said usually and 8 felt they always received the medical support they needed, 3 said usually and 1 said sometimes. 10 staff surveys received, confirmed that 5 staff were involved in care planning for residents and 4 were not, it is noted that some of these staff were not care staff. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 13 Comments received from people using the service were mostly complementary and included; “There is a friendly atmosphere which tries to cater for individual needs”, and “Staff do not always listen and act on what you say”. “I am very happy and contented here” “I am very happy with all aspects of the Rosary” and “The staff are very supportive with a lovely sense of humour” The Medication Administration Records were examined and no gaps were evident. There was evidence of variable doses being recorded and hand transcribed entries being signed by 2 staff. The acting manager has implemented a system to record the administration of all prescribed creams on a record sheet located in the persons bedroom so that staff can sign at the time of administration. People using the service have the option to self medicate should they want to and risk assessments are in place to ensure safe practice is maintained. Lockable storage is available as required. A homely remedy policy is in place with signed consent on agreed protocols by the relevant GP’s. The home had 7 oxygen cylinders which were all stored securely. The acting manager is recommended to ensure that prescribed oxygen cylinders stored at the home are returned when no longer needed. All medications were stored safely and securely with systems in place for ordering and disposal. The Rosary Nursing Home DS0000061580.V349137.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 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are opportunities for social stimulation and people are supported to join in with organised activities or pursue their own interests. The meals in the home are of a good quality and a wide range of choice is available. EVIDENCE: Resident’s surveys asked are there activities arranged by the home that you can take part in,4 -always, 7 –usually and 1-sometimes.Comments included “ Entertainment and outings are well arranged with variety”, “There are plenty of activities if I so wished”,one comment stated, “As my relative is still astute, life at times is a bit boring for them” The inspector spent time talking with people using the service and observed people reading newspapers and chatting to staff. The planned activities are advertised in a monthly newsletter and also on a board in the front hallway and around the home. The home employs 2 activity coordinators and one was seen to be working on both days of inspection. People using the service stated that there were no strict routines in the home and that they were free to decide how and where they spent their time. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 15 Everyone who expressed an opinion stated that they have choice about all aspects of their care and are comfortable to request any particular preferences. There are a variety of organised activities including entertainers, quizzes, bingo, arts and crafts, Church Services and social events. In the lounge there was a TV, radio, books, magazines and newspapers. On the first day of inspection there were noted to be arts and crafts upstairs and a quiz downstairs and on the second day of inspection there was a visitor to the home leading singing in the morning and a multicultural celebration taking place in the afternoon. The multi cultural event was a celebration of the diversity of cultures within the staff and service user group and involved the staff sharing their cultural food and dancing with staff and people using the service. The records of activities included a social history for each person within the care plan and a further record of who was involved and how they participated and enjoyed the event. The home maintains a record within the rooms of people who spend a lot of time in their bedrooms to record social interaction between staff and people using the service. It was discussed with the acting manager that 8 pairs of unmarked glasses were on the side unit in the upstairs lounge. Staff told the inspector that they were “spares”. The acting manager said that they would be removed to prevent being used for the wrong person. On the second day of inspection it was observed that they were still there. The acting manager is recommended to ensure that all people who wear glasses have the correct glasses available to them and any unidentified pairs be removed. The care staff provide breakfast each morning to the people using the service’s bedrooms, the main meal of the day is at lunchtime and there is a pleasant dining room available on each floor. The tables were nicely laid with a choice of condiments and drinks to have with their meals. There is a choice of meal at both lunch and teatime and one person explained that should you not like the choice there are always further options available. On the day of inspection lunch was a choice of sausage in onion gravy or cheese and tomato flan, boiled potato, green beans and leeks with milk jelly for desert. Tea was beans on toast, sandwiches and strawberry mouse. One person was seen to have a jacket potato with cheese as an alternative. Lunch the following day was fish and chips in line with the multicultural celebration of a traditional English meal. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 16 The inspector observed lunch being served both in the dining rooms and also people’s bedrooms and it appeared to be enjoyed by all. People who required assistance were helped in a dignified and discreet manner. People using the service with specific dietary needs and preferences were catered for and contact with the Community Dietician is made as and when required. The inspector visited the kitchen and noted that stock levels were good and the standard of hygiene was being maintained. Resident’s surveys asked if residents like the meals at the home, 2-always, 6usually and 3- sometimes.. Comments included: “Food is varied there is always a choice”, ”The food is of varying quality”, ”The food quality is poor probably due to a lack of sufficient funding.” And “ There is more you can do with potato other than mash” On both days of inspection the meals appeared plentiful and people using the service confirmed that they had enjoyed them. The Environmental Officer visited the home in July 2006 and the acting manager addressed all issues identified. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 17 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 17 18 19 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and residents are confident that the homes management team would appropriately deal with any complaints or concerns. Policies, procedures and training are available to staff to ensure they have the knowledge to prevent service users from the risk of abuse EVIDENCE: 5 relatives surveys and 10 people using the service surveys, confirmed that they knew how to make a complaint and surveys confirmed that people knew who to speak to if they were unhappy. All 10 staff surveys confirmed that they were aware of policies about protecting vulnerable adults and how you report any concerns about poor care practice or allegations of abuse. The home has an induction programme which includes abuse awareness and also had booked staff training for the week of inspection regarding abuse awareness. All staff were aware of the whistle-blowing policy. The policy was examined and it is recommended that the contact details for CSCI are included in the policy. The complaints procedure is displayed in the main hall. The homes complaints record was examined and the home has received 5 complaints, which have all been dealt with within an appropriate timescale, and response in writing has The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 18 been made. CSCI has received one of the above complaints which was investigated by the home to a satisfactory outcome. People using the service told the inspector that they would be comfortable to approach the acting manager or a member of staff with any worries or concerns. Staff also confirmed that they were happy to approach the management with any concerns and would be confident that they would be dealt with promptly and appropriately. All 10 staff surveys received confirmed that they had received a Criminal Record Bureau Check and examination of recruitment files confirms that these check were undertaken before staff commenced employment. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 19 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 20 21 22 23 24 25 26.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a large building with some parts of the building suffering from wear and tear that would be typical of a building of similar age and usage. The gardens are suitable for people using the service use and the home appeared to have a good standard of hygiene. EVIDENCE: The home is an older building with a newer build added on to provide accommodation on 2 floors and provides 3 lounges and 2 dining rooms. All areas are well furnished and decorated. Personal accommodation is located on each of the floors of the home and is accessible to people with all levels of mobility. Stairs and lift access is available to each floor. All bedrooms seen by the inspector were comfortably furnished and had been personalised to reflect the tastes of the individual. People using the service are The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 20 able to bring personal effects and small items of furniture with them when they move to the home, which gives rooms an individual homely feel. Various aids and adaptations have been put in place to assist service users to maintain their independence. Specialist pressure relieving cushions and mattresses were seen were there was an assessed need and specialist profiling beds were seen. All wheelchairs were seen to be clean and maintained. Toilet and bathing facilities are provided in sufficient numbers and were clean and odour free, all areas appeared warm, clean and appeared fairly well maintained. One maintenance staff was seen working on the day of the inspection and it is clear that the home has an ongoing maintenance programme. New carpets for the upper floor corridors have been fitted since the previous inspection. One en-suite bathroom required the seal behind the sink repairing and this was referred to the acting manager. 6 residents surveys confirmed that the home is always clean and fresh and 5 said usually. Comments received include “The home provides cleanliness and comfort” The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 21 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 30 Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are adequate to meet the assessed needs of people using the service and staff training is promoted to support service users. The induction process for staff is adequate to ensure staff are training to meet the people using the service needs. EVIDENCE: The inspector spend time talking to people using the service and every person was extremely complementary about the kindness and caring attitude of the staff. The home ensures that there are always qualified nursing staff available on each floor of the home over each 24 hour period. On the day of inspection there were 3 qualified nurses and 11 care staff and staff confirmed that this is a sufficient staff number to provide the care required. Resident’s surveys asked if staff were available when you need them said, 4 always, 8-usually. The inspector observed staff talking and laughing with people using the service and the interaction appeared comfortable and genuine. People using the service appeared to have developed relationships with the staff that were based on affection and humour. Several people using the service commented that they had to wait when they The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 22 had summoned assistance with the call bell. All people who discussed this with the inspector felt that they did not have to wait too long and that staff would always explain the delays. This information was discussed with the acting manager on the day of inspection One person using the service was noted not to access to a call bell, the acting manager was informed of this. Service users comments included; At busy times a short wait is inevitable Staff shortages occasionally contribute to non availability of staff This is a happy home they could constantly do with more staff the present staff do not have time to socialise with the residents and I am sure they would like to Sometimes take a long time answering the buzzer and opening a window for fresh air Comments received from staff surveys included-“I often see staff chatting when they have a few minutes with residents as I like to also”. “There is “Good team work and support”.” I have been made to feel very welcome by all members of the staff-everyone seems committed to their role at The Rosary.” “This is a very happy well run home.”, “ the staff are just lovely” and one staff commented, “I always find all the staff very helpful and approachable and I love working here”. Relatives survey comments were all complimentary and included ;Staff are always polite and caring, clean and well dressed We could not look after my relative in the way the carers and nurses care for them I could not ask for better The staff are extremely kind and caring and take great steps to know the individuals likes/dislikes and take them into account, my relative is treated as an individual and afforded respect. The staff are in my opinion a dedicated team who do their up most. The staff are excellent 10 staff returned comment cards to CSCI, all 10 staff confirmed that they felt they had received adequate induction and supervision when they commenced their job. The acting manager forwarded to the inspector a copy of the homes induction programme and it was noted to be detailed and comprehensive. All 10 staff confirmed that they were clear of what the service users needs were and also all 10 staff were aware of the duties they must not undertake. All staff spoken with at inspection were aware of whistle blowing and complaints procedures within the home and abuse awareness training was part of the induction training and further training was planned for the week of inspection. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 23 The acting manager stated that 51 of staff have completed NVQ training in health and social care and this number should increase to 78 by the end of October 2007. Robust recruitment procedures were seen to be in place to protect people using the service from the risk of abuse. The acting manager is recommended to ensure that an employment history of approximately 10 years is received before staff commence employment. One comment received from a visiting health professional was – “Communication standards are variable, some staff appear to have limited English”. The acting manager must ensure that all levels of communication ensure the safety of people using the service. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 24 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 32 33 35 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed and benefits from the positive and proactive management style of the acting manager Systems are in place to ensure the health and safety of service users whilst encouraging and promoting independence. EVIDENCE: The acting manager of the home is Lyn Taylor who has managed the home for 6 months. Discussions with the inspector confirmed that she has a clear understanding of the needs of the people living at the home and strives to develop a team of staff to provide a high standard of care at all times. One staff commented, “I am very happy here I can always approach our unit manager for advice/information and she listens” and The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 25 “Our manager and RGNs always have time for any questions or comments I may have”. The home undertakes regular audits of care by surveying the opinions of the residents and their families. This was last done in May-June this year. Comments made on these questionnaires are audited and an action plan made to address any issues identified. There are established systems in place for dealing with people using the service’s finances. The inspector evidenced that each service users personal monies were stored in individual envelopes with a running total of deposits and withdrawals. All service users records are stored confidentially in line with the Data Protection Act; care plans in use are stored in trolleys on each unit with lockable lids attached when not in use. 8 staff stated on the comment cards supplied that they were receiving regular supervision; records supplied at inspection supported this. Accident records were viewed and were seen to be reviewed and audited monthly for trends and regular occurrences and action taken to reduce any risks of further accidents taking place. Maintenance records were well maintained and up to date these included ; * * * * * * * * * * * * * Fire Extinguishers Hoist Servicing Emergency lighting PAT Tests Boiler servicing COSHH Hot water temperatures Wheelchair maintenance Electrical Hard Wiring Fire System Lift servicing Nurse call servicing Accident audit. 10 staff surveys received stated that they were provided with protective clothing and necessary equipment to do their work safely and cleaning staff confirmed that they had access to COSHH data sheets and had received training in the safe use of chemicals. The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 26 . The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 27 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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The acting manager is recommended to ensure that protocols are available for staff information within the care plan for people with the specific nursing intervention of Sub Cutaneous Infusions. Further night care plans for all people using the service are recommended. The registered manager is recommended to ensure that all oxygen cylinders no longer needed are returned to the appropriate oxygen provider. The acting manager is recommended to ensure that all people who wear glasses have the correct glasses available to them and any unidentified pairs be removed . The acting manager is recommended to include the contact details for CSCI in the whistle-blowing procedure available within the home. The acting manager is recommended to ensure that an employment history of approximately 10 years is received before staff commence employment. DS0000061580.V349137.R01.S.doc Version 5.2 Page 29 2. 3. 4. 5. OP9 OP14 OP18 OP29 The Rosary Nursing Home The Rosary Nursing Home DS0000061580.V349137.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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