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Inspection on 19/09/05 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 19th September 2005.

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. Service users spoke of the kindness of staff. Staff are well trained and supervised. They have access to in-house training and supervision and are encouraged to participate in NVQ programmes 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. Those service users spoken with, who were able to express a view, informed the inspectors that they liked living at the home and enjoyed the food. Service users benefit from a wholesome and varied menu that takes into account the needs and preferences of people living at the home. Special diets are catered for and choices are offered. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors.

What has improved since the last inspection?

The manager, Annette Denson, is now established in her role and during the inspection was confident and assured in her role.

What the care home could do better:

Two service users made comments about overcooked vegetables. On the day of inspection the vegetables did appear rather soft. Short-term care needs should be recorded in the care plans rather than the daily records.

CARE HOMES FOR OLDER PEOPLE The Rosary Nursing Home Mayfield Drive Durleigh Bridgwater Somerset TA6 7JQ Lead Inspector Shelagh Laver Unannounced 19 September 2005 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 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 D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 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 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 Ms Annette Denson. Care Home with Nursing 63 Category(ies) of Old Age (63) registration, with number of places The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to three persons for respite care, for people aged 45-64 years, for a period of up to 28 days. 2. To provide care for one named person, aged 45-65 years, with learning difficulties. Date of last inspection 15th March 2005 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. 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/630 Kg and one four-person/300 Kg, 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. All bedrooms are fitted with telephone sockets. There is a Registered Nurse on duty at all times. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 19th September and was conducted by two inspectors over six hours 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: What has improved since the last inspection? The manager, Annette Denson, is now established in her role and during the inspection was confident and assured in her role. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 6 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 Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4, 5. The manager ensures that the home can fully meet the assessed needs of prospective service users prior to making a decision about admission. The pre-admission process is detailed and well managed. The manager ensures that prospective service users are provided with appropriate information that 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 £520-£580 dependant upon the room to be occupied and the assessed needs of the service user. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 9 The manager ensures that prospective service users are fully assessed prior to admission. 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 three care plans examined. Contracts for service users were examined and found to be detailed and comprehensive. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10. 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 D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 11 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 user’s heath needs was improved when possible. Medication management has improved. Creams should have an opening and discarding date. As a result of changes to the disposal arrangements for drugs from nursing homes a waste disposal contract must be formalised. There have been two drug errors reported to CSCI and the manager must continue to audit drug administration to ensure standards are maintained. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15. Service users are able to chose a variety lifestyle patterns in the home. The home provides a wholesome and varied menu which takes into account the needs and preferences of service users. 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: Daily life has a routine but this can be tailored to accommodate individual preferences. There is a menu which is wholesome, varied and takes in to account the needs and preferences of service users. There was evidence of choice and fresh fruit and vegetables. One service spoke of the efforts made to ensure she had something to eat she liked. Care is taken to ensure that soft diets are appealing and wholesome. Menus are regularly reviewed and the home seeks the views of a dietician when needed. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 13 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 home has a dedicated activities organiser. Notices advertise a balance of regular activities and special events. Service users said they are free to choose whether they join in with an organised activity or not and some “made their own amusement”. One person has a computer, another is able to go out regularly. Records of activities were seen to be maintained to a good standard. The inspector observed the house newssheet “The Rosary Newsletter”. This gives details of forthcoming social events and news of service users and staff. Forthcoming events included a keyboard player and the Weston Gospel Male Voice Choir. There is also a review of the previous months entertainment. The manager stated that one to one time was provided for some service users. All staff attended to and addressed service users with respect and in a dignified manner. The hairdresser visits weekly. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 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 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: The inspector observed the complaints file. Seven issues were recorded and all had been fully investigated and resolved. One had been referred to CSCI. The complainant had been satisfied with the actions of the manager in resolving the complaint. Service users spoken to knew whom they were able to speak to if they wished to complain and felt they were encouraged to bring all issues forward. Staff recruitment procedures, training, supervision contribute to the protection of service users from abuse. In future no “to whom it may concern” references must be accepted by the home. Agencies supplying overseas staff must be made aware that this is not acceptable. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 15 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 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 D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 16 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 D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30. The home ensures that there are sufficient staff on duty to meet the service user 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: There is a suitably trained staff team. The home had an adequate staff number on duty at this inspection. Staff vacancies have been reduced. There is an innovative approach to training using company training materials. Manual handling up-dates, fire training, dementia care, catheter maintenance and diabetic care training were mentioned by staff. 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 that must be fully implemented. It is not acceptable to use “To whom it may concern” references from recruitment The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 18 agencies. Application forms must include details of previous employment. Any gaps in employment should be explored and noted on the interview records. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. Staff confirmed, “She knows what is going on”. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 20 Staff benefit from regular meetings and supervision sessions. Records were seen to support this. There are established systems to manage the finances of the home. Sanctuary Care health and safety policies and procedures give clear guidance on all aspects of health and safety. The inspectors were concerned to observe the manual handling practices of a visiting health professional. The manager must discuss these practices with the person concerned. 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. 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. 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 include action to be taken and evidence of analysis. 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. Those checked at this inspection were found to be within the acceptable limits. First aid training is provided for staff. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 22 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Requirement Two personal references must be obtained for all staff. To whom it may concern references are not acceptable. Prescription cream administration must reflect best practice. The system for disposing of surplus medicines must be formalised. Timescale for action 1/11/05 2. OP9 13(2) 16(k) 1/11/05 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 Care plans should reflect the short tem care needs of the service users. The Rosary Nursing Home D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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 D53 - D02 S61580 The Rosary V240665 190905 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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