Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 23/05/06 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 23rd May 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 training programme implemented in the home. Staff training is very well planned and resourced. The areas of staff training are linked to the staff job profile and appraisal and supervision sessions are used to highlight any further areas needing training. A variety of training sources are used including in-house training, external day courses and distance learning courses. Induction training is clear and comprehensive and staff are suppoted throughout their induction. A recent visit has taken place from a Consultant in Dementia Care to highlight areas needing further work in this area. Service users were very complimentary about the kindness and caring nature of the staff. Comments include "I am very happy here " "Can only speak very highly, very nice bunch all of them". Service users benefit from a clean and well maintained environment. The maintenance of the home is ongoing, clear and current records were available of all maintenance undertaken to ensure the health and safety of service users.

What has improved since the last inspection?

The standard and presentation of meal-times is now much improved. The home took a very active approach to this issue. The home surveyed meal times and looked carefully at the issues raised from this, they then altered the amount of time service users sat in the dining room awaiting meals. The manager developed an audit tool and asked a range of staff, including maintenance staff to perform this audit in an attempt to get a broad picture of meal times as an experience Comments from service user surveys were also highlighted and an action plan formulated. The range of menu has been altered taking into consideration the views of the service users. The cook confirmed that the choice of menus was discussed with the service users, relatives and staff members. This auditing process has continued to ensure a good service is being provided. The choice for each day is collected from service users the day before and the menus are displayed on each floor of the home.

What the care home could do better:

Care planning requires further work to ensure a person centred approach. Care plans lacked personal details to individualise their care. The service user or representative did not consistently sign bed rail consent forms and the weights were not always done as regularly are service users care needs would require. Activity planning may need review to ensure that service users who remain in bed have some recreational activity and that it is recorded. Oxygen cylinders are required to be stored correctly and ensured that they are secured to the wall. Service users creams are required to have the correct date of opening and signature on each item. It is required that personal items used when bathing such as toiletries and razors are returned to the service users own rooms after use. The lockable storage in the bathrooms should be used to store any chemicals in the bathrooms. It is recommended that the appropriate manufacturers perform the necessary repairs to the call-alarms, hot water systems and dishwasher promptly. Some issues remain concerning lost laundry items , however the laundry staff can confirm that steps to remedy this are being taken.

CARE HOMES FOR OLDER PEOPLE The Rosary Nursing Home Mayfield Drive Durleigh Bridgwater Somerset TA6 7JQ Lead Inspector Gail Richardson Unannounced Inspection 23rd May 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.V292938.R01.S.doc Version 5.1 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.V292938.R01.S.doc Version 5.1 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.V292938.R01.S.doc Version 5.1 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. 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 Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 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 on the 23rd and 24th May 2006. A tour of the home took place and all the bedrooms and communal areas were seen. There were 58 service users and 3 respite residents currently residing at the home, with one service user in hospital. The inspectors spoke to 14 service users, 3 visitors and 10 members of staff, the Registered manager was available throughout both days of the inspection. As part of this inspection the inspectors surveyed the opinions of a random selection of service users and their representatives, GP’s , District Nurses and Care Workers. A small amount of responses were received. Records relating to care, staff , finances and health and safety were examined The inspectors noted that on both days service users appeared settled and comfortable and there was a pleasant atmosphere within the home. The service users looked well cared for with an attention to detail of personal care was evident. Staff spoken to were complimentary about working in the home and time spent by the inspectors observing staff, evidenced that they were kind and caring towards service users and spoke to them at all time with support and reassurance. Two visitors spoken to were pleased with the care their relatives were receiving and confirmed that they were always made very welcome to the home at any time. The inspectors would like to thank the service users and staff for their time and hospitality through out the inspection. 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. What the service does well: The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 6 Service users benefit from the training programme implemented in the home. Staff training is very well planned and resourced. The areas of staff training are linked to the staff job profile and appraisal and supervision sessions are used to highlight any further areas needing training. A variety of training sources are used including in-house training, external day courses and distance learning courses. Induction training is clear and comprehensive and staff are suppoted throughout their induction. A recent visit has taken place from a Consultant in Dementia Care to highlight areas needing further work in this area. Service users were very complimentary about the kindness and caring nature of the staff. Comments include “I am very happy here “ “Can only speak very highly, very nice bunch all of them”. Service users benefit from a clean and well maintained environment. The maintenance of the home is ongoing, clear and current records were available of all maintenance undertaken to ensure the health and safety of service users. What has improved since the last inspection? The standard and presentation of meal-times is now much improved. The home took a very active approach to this issue. The home surveyed meal times and looked carefully at the issues raised from this, they then altered the amount of time service users sat in the dining room awaiting meals. The manager developed an audit tool and asked a range of staff, including maintenance staff to perform this audit in an attempt to get a broad picture of meal times as an experience Comments from service user surveys were also highlighted and an action plan formulated. The range of menu has been altered taking into consideration the views of the service users. The cook confirmed that the choice of menus was discussed with the service users, relatives and staff members. This auditing process has continued to ensure a good service is being provided. The choice for each day is collected from service users the day before and the menus are displayed on each floor of the home. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 7 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 DS0000061580.V292938.R01.S.doc Version 5.1 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.V292938.R01.S.doc Version 5.1 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): 1345 Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Prospective service users, relatives and friends are able to visit the home prior to 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 homes current fee range is £567.00 to £610.00 when self funding, dependant on the room to be occupied and the assessed needs of the service user. The home also has service users funded by Local Authorities. Prior to admission service users and their representatives have the opportunity to visit the home to view prospective rooms and communal areas. Three service users and two relatives, confirmed that they had received a brochure The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 10 and one visitor had visited the home twice to view the home to select a choice of room. Eight service user records were examined. Each service user had received a pre-admission visit by the Manager or a representative from the home. Their needs were assessed and documented. Further information from other health care professionals is also taken into account. The home ensures that it can meet the needs of the person assessed and will identify any equipment requirements prior to admission Contracts are issued to all service users, these were not available at this inspection. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 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 Each resident has a care plan, but practice of involving residents in the development and review of the plan is variable. The plan in most cases includes the basic information necessary to plan the individuals care and includes a risk assessment element When developing the plan the home has complied where possible with relevant clinical and social care guidelines. A more person centred approach is recommended to care planning. The homes medications systems are adequate. Further attention is needed to ensure best practice for the storage of oxygen. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms and provides screens in shared rooms. Residents are happy with the way that most staff deliver their care and respect their dignity. EVIDENCE: Eight care plans were sampled at this inspection . The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 12 The SHARPS system of care planning is used. Each care plan contained a full assessment of needs and had been reviewed up to 3 monthly. It was discussed with the Registered Manager that a more person centred approach to care planning is required for service users who have more dependant needs. Short term care needs were not seen in the care plans, this had been discussed in the previous inspection report. The inspectors discussed with the Registered Manager taking a more holistic ,person centred approach to care planning. A greater attention to detail would ensure that care assistants would have clear direction in providing the care required. For example, a service user who prefers to rise early has no clear directions within care plan to ensure that all staff are aware of this. A further service user has been reviewed as requiring weighing every 3 months but had lost considerable weight since the previous time of being weighed. There was no specific care plan details to monitor weight loss and nutritional input. An issue regarding monitoring weight loss had previously been identified by the Regional Manager on a Regulation 26 visit on 10th May 2006. Some elements of the care plans needed further attention including the recording of personal care given and the risk assessments for bedrails consent forms and falls. This had also been identified in the Reg.26 visit. Some areas of care were not contained within the care plan, for example, there was no directions for the care of P.E.G. feed equipment and no instructions for observations for service users receiving Digoxin. The Registered Manager confirmed that the night staff are currently in the process of care planning for the night time period for each service user. There was very little evidence of service user/ relatives input in care planning. The medications systems are mostly well organised. The Medication Administration Records sheets were well organised and without gaps. The Registered Manager explained that there are no service users wishing to self medicate, however the recent Regulation 26 visit by the Regional Manager had highlighted that a service user was self-medicating and no disclaimer was identified in the service users care plan. The oxygen cylinders in the treatment room require securing to the wall. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 13 The creams stored in service users bathrooms are organised into individual boxes and risk assessments are stored in the bathrooms with them. However some creams were not signed and dated when opened. The inspectors witnessed staff interacting with service users throughout the home. At all times the service users were treated with respect and dignity. All service users and relatives spoken to, were happy to comment on the kindness and caring attitude of the staff. For example, “I can only speak very highly of them, they give excellent care, a very nice bunch, all of them “ “They listen to me “, “The girls and young men are very nice”. The Registered Manager confirmed a willingness to liaise with other health care professionals to support service users including Dementia Care Consultants and Tissue Viability Staff. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 The home has developed a system for displaying information and bringing attention to community events and activities. When residents have particular interests every effort is made by staff to help the resident maintain their interest and keep up any community involvement. Family and friends feel welcome and know they can visit the home at any time. Staff always make time to talk to visitors and share information with the agreement of the resident. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. It is clear that the home encourages individuals and groups from the community to visit the home. Service users are able to choose a variety of lifestyle patterns in the home. Development of care planning and recording of activities for those service users remaining in bed is recommended. Residents enjoy the flexibility of meal arrangements and enjoyed being able to eat in their own room if they wished. The home provides a varied and wholesome diet. EVIDENCE: The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 15 The home employs an activities organiser 40 hours per week. A entertainments board advertises forthcoming events. The inspectors saw a variety of activities during the inspection including, flower arranging and a reminiscence quiz. Service users spoken to were aware of the activities available, but several chose not to participate. The inspector observed the house news sheet “The Rosary Newsletter” which included forthcoming events and news items for service users and staff. There was evidence of an recent Easter Bonnet competition and activities are planned around the forthcoming World Cup. The activities organiser explained that she spends some time each afternoon with the day care clients. It was discussed with the Registered Manager that activity planning for those service users who remain in bed should be directed , monitored and recorded in the care plans. The hairdresser visits weekly and was available on the first day of inspection. Service users have a personal choice if they use this service. Three visitors were spoken to the inspectors and were all very happy with the care their relatives received. The confirmed that they had access at all reasonable times and were always made very welcome by the staff. One service user continues to be able to access private prayers and Holy Communion from her local Church. A recent Mini Bus trip had taken service users out for a trip which had been very much enjoyed. Service users rooms were personalised to each individual’s own tastes with personal items and small pieces of furniture. One service user has their cat now living in the home. The Registered Manager explained that service users have the choice and control if they prefer male or female care staff. Meal times were observed. Lunch was served at 12.30pm and was served in two dining rooms and service users own bedrooms.. Previous issues of service users sitting at the dining tables for long periods of time was observed to not be happening. Since the previous inspection a full audit of meals and mealtime routines has taken place. The outcomes of this audit have altered the routine of meal times and the content of the meals. This has had a positive effect on the mealtime experience for service users. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 16 Most service users comments and service user surveys were complimentary about the standard of the meals. Further work in this area is required to ensure the standard continues to improve. Specialist diets are catered for within the home. Inspectors observed that service users had plate guards and clothing protection as required and the staff assisted in an appropriate and discreet manner. The menu was examined and discussed with the cook. The cook, service users and staff members decided the choices of menu through suggestions and personal noted preferences. An alternative is available at each meal time. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 The home has a complaints procedure that is up to date, very clearly written, and is easy to understand. The complaints procedure is widely distributed, and has a high profile within the service, a copy is placed in the front hallway. Residents and others associated with the home demonstrate a good understanding of how to make a complaint and they are very clear of what can be expected to happen if a complaint is made. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures regarding protection of residents are of a high quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer the incident to. EVIDENCE: The complaints file was examined by the inspector. Each issue had been recorded clearly, fully investigated within a reasonable time scale and the out come recorded. Service users and relatives spoken to were confident that should they have any complaints they could approach the management of the home and their issues would be taken seriously. The complaints procedure is prominently displayed in the front hall. Staff recruitment procedures, training and supervision support the protection of service users from the risk of abuse. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected 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 There are two areas that pose a potential risk to service users, these are, the hot water system which is under repair and the call alarm system which is to be replaced. However, the management have recognised these and have taken prompt action to mitigate these risks. A risk assessment is to be performed for the area currently without a working call bell system. Service users are able to personalise their own rooms. The homes environment is able to meet the assessed needs of the service users. The home provides specialist equipment to ensure the needs of service users are met. EVIDENCE: All bedrooms and communal areas were seen at this inspection. The home was clean and appeared well maintained. Three maintenance staff were seen working on both days of the inspection. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 19 Overall the home is pleasantly decorated and maintained. The garden area was accessible to service users and inspectors evidenced an area of raised beds and small greenhouse which has been made suitable for service users. There is access to specialist equipment and adaptations to promote independence. Specialist pressure relieving cushions and mattresses were seen were there was an assessed need. There are suitable and sufficient toilet and bathing facilities. The upstairs bathroom has a temporary repair whilst awaiting parts for repair. The call bell system is awaiting replacement and an area of the home has no call bell facility. The Registered Manager confirmed that an routine is in\place where staff check the area at frequent intervals. The upstairs lounge area did not have a call bell lead and therefore service users were not able to summon assistance. For the time the inspectors sat in this lounge several staff were evident moving in and out of this area. There is level access around the home and service users have access to other floors via a passenger lift. One area had a fire exit obstructed by a chair and training flip chart. Bedrooms were personalised with service users photographs and some small personal belongings. The general standard of cleanliness was good. The cleaning staff confirmed that they received sufficient training and that they considered the domestic hours sufficient to maintain the hygiene of the home. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Residents have confidence in the staff that care for them. Management encourage staff members to undertake external qualifications beyond the basic requirements, and recognise the benefits of a skilled, trained workforce. The service clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications. Residents report that staff working with them are very skilled in their role, and are consistently able to meet their needs. The homes recruitment procedures are robust and complete and protect the service user. EVIDENCE: The home had an adequate staff number of staff on duty on both days of this inspection. Staff rotas evidenced a consistent level of staff on duty. The Registered Manager confirmed that she felt there were enough staff on duty to meet service users needs. The Registered manager confirmed that the home is now almost at staffing capacity. The home employs a full time activities organiser. This role is divided between each floor and day care residents. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 21 The inspectors saw a variety of activities taking place, the organiser advised that she spends a lot of time each afternoon with the day care residents. This may need to be reviewed to ensure that service users who remain in bed are included in some level of activity. There is a training plan for the year which covers induction training and all basic training needs. Training sources are varied with the staff having access to internal training , courses run externally and distance learning programmes. The home has recently had a consultation visit to determine dementia care needs and this is to be linked to staff training in this area. Manual Handling up-dates, fire training, health and safety and food hygiene are planned throughout the year to ensure all staff have the facility to remain updated. Staff appraisal and supervision are an opportunity for staff to identify training needs. These training needs are linked to the job profile to ensure all training areas are monitored. Four staff files were evidenced. These staff members had been employed since the previous inspection. All contained evidence of a thorough company recruitment process. Application forms now include details of previous employment and any gaps in employment history are explored at interview. The Registered Manager confirmed that on some occasions more than the required references are requested to ensure a consistent employment background. Discussions with care staff confirmed that training phases are done in rotation, there will be a period of time containing several training sessions followed by a break. Domestic staff confirmed that they are aware of Data Sheets and receive training in the risks of cross infection. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 36 37 38 The manager is a Registered General Nurse with previous, varied nursing experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running of the home. The manager is resident focused and leads and supports a strong staff team who have been recruited and trained to a high standard. The manager is aware of current developments both nationally and by CSCI and plans the service accordingly. Where the home is responsible for resident’s money it works to a very rigorous system, it maintains very clear records that are routinely kept up to date and can be used to track individual residents finances. The service will continually seek improvements through research and keeping up to date with best practice in the area of equality and diversity. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 23 Some health and safety issues continue to require to ensure safe practice for service users. The needs and well being of service users take priority in the home Staff are appropriately supervised and supported The Health and Safety of service users and staff are adequate. Some maintenance issues remain outstanding. EVIDENCE: The Registered Manager Annette Denson is a Registered Nurse with many years of management experience. She is currently undertaking The Registered Managers Award Level 4. Discussions with the inspectors confirmed that she has a clear understanding of the needs of the service users living at the home. Quality assurance audits of service users and relative’s comments were evidenced. The comments were highlighted and an action plan formulated. A responsible person was allocated to each issue. Issues were discussed wit each department and at staff meetings. Feasible outcome dates are set. Any outcomes are highlighted for further training needs. Minutes of a recent staff meeting were seen and discussions with staff confirmed that staff meetings are held where “you can put your point across without fear of reprisal”. There are established systems in place for dealing with service users finances. The inspector evidenced that each service users personal monies were stored in individual envelopes with a running total of deposits and withdrawals. Staff supervision records were evidenced and a yearly supervision plan was seen. The Registered Manager explained that qualified staff are responsible for supervising a number of care staff each. These Qualified staff are also supported in this role by the Manager and Deputy Manager. Sanctuary Care health and Safety policies and procedures give clear guidance on all aspects of health and safety. It was highlighted by the inspector that pregnant staff must be risk assessed and it is recommended that the staff sign the risk assessment. Further health and safety guidance was advised regarding equipment to assist pregnant staff. Comprehensive maintenance records were seen. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 24 These included : * Fire Extinguishers * Hoist Servicing * Emergency lighting * PAT Tests * Hot water temperatures * Shower Head cleaning * LOWLER servicing * Gas Servicing * Electrical Hard Wiring * Fire System * Laundry Equipment Service * Lift servicing * Boiler servicing * Nurse call servicing * Sluice Machines * Chlorination Certificate * Environmental Health There continues to be a problem with the hot water system. The hot water is tested monthly by the maintenance man to ensure the temperature does not exceed 44 degrees. The inspector randomly tested the water and this temperature was not exceeded. The Registered Manager confirmed that a further boiler is planned to resolve the problems with the hot water. Further difficulties with the nurse call alarm system have meant that one area of the home has an inconsistent nurse call system. The Registered Manager confirmed that a system of room checks is in place until a new nurse call system has been fitted. The Registered Manager has also confirmed that difficulties with the dishwasher have occurred whilst waiting for delivery of a new part. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 25 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 X 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 3 3 2 The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 26 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. 2. Standard OP9 OP9 Regulation 13(4) 13 (2) Requirement It is required that the storage of oxygen is made safe and secure. The home is required to ensure the safe, storage of creams to include the date and signature when opened. Personal items, such as toiletries, are required to be returned to Service users rooms or stored in the locking facilities available. Timescale for action 30/06/06 30/06/06 3. OP38 12(4)(a) 30/06/06 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. 2. 3. Refer to Standard OP7 OP7 OP7 Good Practice Recommendations It is recommended that the home adopts a more person centred approach to care planning which also includes the involvement of Service Users and their representatives. The home is recommended to ensure that bedrail consents are signed and dated by the service user or their representative. It is recommended that the home review the planning for DS0000061580.V292938.R01.S.doc Version 5.1 Page 27 The Rosary Nursing Home 4. OP7 5. 6. OP38 OP38 activities for service users to include those service users who remain in bed. It is recommended that the service users requiring weighing monthly are highlighted in their care plan and done at the correct frequency to correspond with their health requirements. It is recommended that staff who are pregnant are risk assessed and sign the risk assessments as required. It is recommended that the necessary repairs on the Call Bell system ,Hot Water system and Dishwasher are done promptly by the appropriate manufacturers. The Rosary Nursing Home DS0000061580.V292938.R01.S.doc Version 5.1 Page 28 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.V292938.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!