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Inspection on 12/01/06 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 12th January 2006.

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

Service users` benefit from the professional and caring skills of nurses and care staff. The manger has the support of some very committed trained staff who are willing to take on additional responsibilities. Service users spoke often of the kindness of staff. This is a large home with many very dependent service users. The staff are managed to work in teams and there is a named nurse and key worker system. Efforts are made to promote individuality. Comments included "Very homely and happy place." It is a credit to the staff that a service user can say this in a big nursing home. Staff are well trained and supervised. They have access to in-house training and supervision and are encouraged to participate in NVQ Programmes (although these are progressing slowly at present) and external training events. The manager takes appropriate action to ensure that admissions only take place if the home is sure that the assessed needs of a prospective service user can be met. The manager is pro-active in accessing the support of other health care professionals to ensure service users receive holistic care. Service users benefit from a safe, clean and pleasant environment. There is a real effort to provide some enjoyment for service users in the home. The home organises activities and special events. Recently parties had been organised for service users with special birthdays. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. There is support in terms of operational guidance, policies and auditing of systems from Sanctuary Care. There are clear records of the induction process and evidence of commitment to the process from the named mentor.

What has improved since the last inspection?

At this inspection there were no requirements for medication administration. It is evident that there is continuing investment in the home.

What the care home could do better:

It was disappointing at this inspection to hear negative comments about the food from service users. The need to address both the quality of the food provided and the way in which it is served was confirmed by the observations of the inspectors at lunch time on the day of inspection. Service users commented that beverages were sometimes cold. It is recommended again at this inspection that short term care needs, for example chest infections, are identified in the main care plan and not simply recorded in the daily records.There were some comments that items of laundry were lost. At times service users felt there was a delay before their bells are answered. This was an item at a recent staff meeting.

CARE HOMES FOR OLDER PEOPLE The Rosary Nursing Home Mayfield Drive Durleigh Bridgwater Somerset TA6 7JQ Lead Inspector Shelagh Laver Announced Inspection 12th January 2006 09:30 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 The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 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.V270177.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Rosary Nursing Home Address Mayfield Drive Durleigh Bridgwater Somerset TA6 7JQ 01278 431164 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 Miss Annette Peta Joy Denson 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.V270177.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 one named person aged 49 - 65 years with learning difficulties. 19th September 2005 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 eight-person/ 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 Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on 12th January 2006 and was conducted by two inspectors over seven hours. In preparation for the inspection comment cards were circulated to service users and their relatives. It was clear from the number returned that the home had encouraged service users and relatives to complete them and this was helpful. Twenty seven service user returned cards. All stated that they felt safe and were treated well at the home. All felt staff treated them well. All felt safe. Service users spoken to during the course of the inspection confirmed this. Thirty seven comment cards were received from relatives and visitors. Thirty five were satisfied with the overall standard of care. They felt they were welcome in the home at any time. There was praise for the home. “Staff are friendly welcoming and very caring”, “Staff are capable and helpful”, “When my father was unwell staff responded with speed, kindness and efficiency”. There were some negative comments that are addressed in the report. These included comments on the standard of food, some problems with hot water supply and lost laundry. One relative has been encouraged to speak to the manager. A tour of the premises took place where a selection of bedrooms and all communal areas were seen. Twenty service users and ten staff were spoken with. The registered manager was available throughout the inspection. Records relating to care, staff and health and safety were examined. What the service does well: Service users’ benefit from the professional and caring skills of nurses and care staff. The manger has the support of some very committed trained staff who are willing to take on additional responsibilities. Service users spoke often of the kindness of staff. This is a large home with many very dependent service users. The staff are managed to work in teams and there is a named nurse and key worker system. Efforts are made to promote individuality. Comments included “Very The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 6 homely and happy place.” It is a credit to the staff that a service user can say this in a big nursing home. Staff are well trained and supervised. They have access to in-house training and supervision and are encouraged to participate in NVQ Programmes (although these are progressing slowly at present) and external training events. The manager takes appropriate action to ensure that admissions only take place if the home is sure that the assessed needs of a prospective service user can be met. The manager is pro-active in accessing the support of other health care professionals to ensure service users receive holistic care. Service users benefit from a safe, clean and pleasant environment. There is a real effort to provide some enjoyment for service users in the home. The home organises activities and special events. Recently parties had been organised for service users with special birthdays. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. There is support in terms of operational guidance, policies and auditing of systems from Sanctuary Care. There are clear records of the induction process and evidence of commitment to the process from the named mentor. What has improved since the last inspection? What they could do better: It was disappointing at this inspection to hear negative comments about the food from service users. The need to address both the quality of the food provided and the way in which it is served was confirmed by the observations of the inspectors at lunch time on the day of inspection. Service users commented that beverages were sometimes cold. It is recommended again at this inspection that short term care needs, for example chest infections, are identified in the main care plan and not simply recorded in the daily records. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 7 There were some comments that items of laundry were lost. At times service users felt there was a delay before their bells are answered. This was an item at a recent staff meeting. 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 Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 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.V270177.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. The manager ensures the home can meet the needs of prospective service users. The pre-admission process is detailed and well managed. The manager ensures that prospective service users are provided with appropriate information which will assist them in making a decision about admission EVIDENCE: The home has produced a Statement of Purpose and Service User Guide which is made available to service users, prospective service users and their representatives. The home’s current fee range is £540-£580 when self funding, dependant upon the room to be occupied and the assessed needs of the service user. The home has service users funded by Local Authorities and Continuing Care. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 10 The manager ensures that prospective service users are fully assessed prior to admission”, “If I have any doubts I don’t take them”. The home ensures that it can meet the needs of the person assessed and will identify any equipment requirements prior to admission. The manager stated that a service user is visited and information from other health professionals and for example hospital care notes are taken into account. Service users are invited to visit the home whenever this is possible. Documentation relating to pre-admission assessments was seen in the twelve care plans examined. Contracts for service users were examined and found to be detailed and comprehensive. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. The home takes appropriate action to ensure the health care needs of service users are met. The home’s procedure for the management and administration of medication is sound but attention is needed to ensure compliance with best practice. Service users are treated with respect. Care practices support privacy and dignity. EVIDENCE: The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 12 Twelve care plans were sampled at this inspection and were found to be of a good standard. There was evidence of the service users input and of community care professionals being involved with the service user. There was evidence that specialist health care was available through visits from nurses and links with outpatient clinics. It was seen in care plans and medication charts that service users receive treatment for short term and chronic conditions. There was evidence that staff are pro-active in requesting appropriate medical support. There was evidence in care plans that wounds healed and service users heath needs were improved when possible. Medication management appeared to be well organised on this occasion. A waste disposal contract for unused medication has been formalised. The inspector observed several cards sent to the home thanking staff for the care and kindness given to service users at the end of their lives. “Thank you for your care and concern”, “Your hard work, caring and kindness has been much appreciated”. One family “appreciated the high standards of care”. One member of staff has attended a Palliative Care course and there is a willingness in the home to liaise with other professionals to support service users with pain relief and specialist therapies. All service users who returned comment cards felt they were treated with respect and that their privacy was respected. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Service users are able to chose a variety lifestyle patterns in the home. The home provides a varied menu however the standard and presentation of the food requires review. The assistance to service users at meal times could be improved. There must be a system of auditing the standard of food provided. Arrangements for service users to maintain contact with family and friends is good. The home provides activities and entertainments to enrich the service users lives. EVIDENCE: The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 14 Daily life has a routine but this can be tailored to accommodate individual preferences. Some service users enjoy coming into communal rooms others prefer to stay in their bedrooms. There is a menu which appears wholesome and varied. However since the last inspection there have been some problems with the staffing of the catering department which has only recently been resolved. Comments from service users both on comment cards and during the inspection indicated that while food was adequate in quantity and “usually edible”. There was room for improvement. This was particularly evident in the upstairs dining room on the day of inspection. There were several comments about tough meat and on the day of the inspection this appeared to founded. Service users had difficulty chewing the meat that was served in cubes that were large for service users to manage. There were also concerns about the presentation of the meals. Not all trays taken to service users rooms were covered. Not all service users who would have benefited from a plate guard had them. Some service users who were seated in wheel chairs for their lunch were having difficulty in reaching their meals. Whilst one carer demonstrated good practice and sat next to a service user giving assistance another did not. A review of the presentation of the meals and training in best practice in supporting service users at meal times must be undertaken. The home provides a congenial and pleasant atmosphere in which to eat meals and the standard of food served on the day of the inspection did not reflect the general standards of the home. There must be a system of auditing the standard of food provided. Menus are regularly reviewed and the home seeks the views of a dietician when needed. Visitors are made welcome at any reasonable time in accordance with the wishes of the service user. During the inspection visitors were observed in the sitting rooms and in service users rooms according to preference. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 15 The home has a dedicated activities organiser. Notices advertise a balance of regular activities and special events. The inspector observed a game of bingo with small prizes that was enjoyed by all participants and observers. Service users said they are free to choose whether they join in with an organised activity or not. Records of activities were seen to be maintained to a good standard. The inspector observed the house news sheet “The Rosary Newsletter”. This gives details of forthcoming social events and news of service users and staff. There were details of the events organised through the Christmas period. These had included musical events, trips out and ‘Carols by Candlelight’. One service user said Christmas had been “much better here than at home!” All staff attended to and addressed service users with respect and in a dignified manner. The hairdresser visits weekly although some service users did not use the service. The deputy manager said that this was personal choice and all service users would have their hair washed and blow-dried. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18. The complaints procedure in this home is good with evidence that the views of service users/visitors are listened to and acted upon. Procedures and policies aim to protect service users from abuse. EVIDENCE: A complaints file is kept. Issues were recorded and all had been fully investigated and resolved. Service users spoken to during the inspection knew who they were able to speak to if they wished to complain and felt they were encouraged to bring all issues forward. Of the 27 comment cards returned to the inspectors however, 14 stated they were aware of the complaints policy and 13 said they were not aware. The complaints policy is prominently displayed inside the front door. Staff recruitment procedures, training, supervision contribute to the protection of service users from abuse. It was observed that the company no longer accepted ‘to whom it may concern’ references and personalised references for new overseas staff were observed in staff files. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. Service users live in a comfortable, safe and clean environment and are able to personalise their own bedrooms. The home’s environment is able to meet the assessed needs of service users. The home provides specialist equipment to ensure the needs of service users are met. EVIDENCE: All communal areas and most bedrooms were seen at this inspection. The home was clean and well maintained. There was continued evidence of substantial financial investment in the home by Sanctuary Care. New carpets, furniture and pictures were observed in addition to investment in the fabric and maintenance of the building. There is access to equipment and The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 18 adaptations to promote independence. Specialist beds and pressure relieving equipment were seen to be in place where there was an assessed need. There is level access around the home and passenger lifts between floors. Bedrooms were pleasant and comfortable and it was evident that service users were encouraged to bring personal possessions into their rooms. Overall the home is very pleasantly decorated and well maintained. The standard of cleanliness was very good. Domestic staff on duty were satisfied with the time provided to care for the home and the equipment provided. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 &30. The home ensures that there are sufficient staff on duty to meet the service users’ needs. The home’s recruitment practices are robust and designed to protect the service users. Staff are well trained and have access to a range of mandatory and developmental training opportunities. EVIDENCE: The home benefits from the reliability and commitment of a suitably trained staff team. The home had an adequate staff number on duty at this inspection. There have been some trained staff changes such as retirement. Staff vacancies are on-going but are managed. The manager and her deputy are committed to maintaining staff at the appropriate level and described the many hours that can be spent to ensure staffing levels are maintained. The Commission was informed on one occasion when staffing was particularly challenging. There is a training plan for the year to cover all basic training. There is an innovative approach to training using company training materials. Manual handling up-dates, fire training, health and safety, food hygiene and infection control training are all noted on the plan. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 20 Six staff including the manager are taking a distance learning Occupational Health and Safety certificate. There is further training planned on the SHARP care planning system. Trained staff are encouraged to identify training needs as part of their PREP requirements. Sanctuary Care is developing further training for all staff in caring for service users with dementia. Training needs are identified at staff appraisals and any training need identified within the home is noted for action. Five recruitment files were observed. All contained evidence of a thorough company recruitment process. Application forms must include details of previous employment. Any gaps in employment or other issues explored at interview should be recorded. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 & 38. The home is effectively managed by the registered manager. The needs and well-being of service users take priority in the home. Staff are appropriately supported and supervised. The home’s systems for ensuring the health, safety and welfare of service users and staff have improved since the last inspection. EVIDENCE: The registered manager, Annette Denson, is a registered nurse with many years of management experience. She demonstrated through discussion with the inspector and through interaction with staff that she had a very clear understanding of the needs of service users living at the home. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 22 Minutes of recent staff and relatives meetings were seen. Practice issues and service users concerns were addressed. There are established systems to manage the finances of the home and formal audits are undertaken by the company. Sanctuary Care health and safety policies and procedures give clear guidance on all aspects of health and safety. At the time of this inspection, the home was taking appropriate steps to ensure the health & safety of service users, staff and visitors to the home. Comprehensive maintenance records were observed. These included: FIRE – Records indicated that appropriate checks were being carried out on the home’s fire detection and fire fighting equipment. Regular training is conducted for all staff. SERVICING – Servicing schedules indicated that hoists are serviced according to LOLER regulations. There are planned dates for all servicing of all catering and laundry equipment. Bedrails are in use for those service users with an assessed need. Regular checks are made by the home to ensure they remain safe. The home policy and signature of service user/representative were seen. ACCIDENT– The home maintains appropriate records relating to accidents at the home. The accident records are audited monthly. Pressure damage audits are also recorded monthly. HOT WATER/SURFACES – All radiators are of a low surface temperature type which reduce the risk of injury to service users. Bath hot water outlets are thermostatically controlled to reduce the risk of scalding. Monthly checks are made to ensure that the temperature does not exceed the HSE recommended limit of 44° C. There continue to be problems of hot water supply despite action taken by the home and qualified contractors. In one particular bedroom this is a source of concern to the service user. First aid training is provided for staff through the company in-house training scheme. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 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 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP15 Regulation 16 (i) 13 (4) b Requirement The standard and presentation of the food requires review. The assistance to service users at meal times must be improved. There must be a system of auditing the standard of food provided. Timescale for action 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations Discussions at staff interviews related to gaps in application forms or previous history should be recorded in the staff recruitment file. Action to remedy the problem with the hot water should continue. The service user most affected should be kept informed of any progress or plans. 2 OP 25 The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 25 3 OP 7 The short term care needs of service users should be recorded in the main body of care plans not just in the daily records. The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. Extracts may not be used or reproduced without the express permission of CSCI The Rosary Nursing Home DS0000061580.V270177.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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