Inspection on 21/02/07 for The Rowans Care Home

This inspection was carried out on 21st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

The Rowans Care Home 14/11/07

The Rowans Care Home 30/08/05

The Rowans Care Home 05/05/05

The Rowans Care Home 19/10/04

The Rowans Care Home 20/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Rowans Care Home Owen Street Coalville Leicestershire LE67 3DA Lead Inspector Susan Lewis Key Unannounced Inspection 21st February 2007 9:30 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 Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Rowans Care Home Address Owen Street Coalville Leicestershire LE67 3DA 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) 01530 814466 01530 814455 www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Vacant Care Home 54 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30), Old age, not falling within any other of places category (24), Physical disability (54), Physical disability over 65 years of age (54) The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. No one under the age of 50 years of category PD to be admitted into the home To be able to admit the person of Category LD(E) identified in correspondence with the previous registration authority dated 27th March 1998 No person under 55 years of age who falls within category DE may be admitted to the home The service users admitted to the home who fall within category OP may only be accommodated on the ground floor The service users admitted to the home who fall within the sole category of PD or PD(E) may only be accommodated on the ground floor. First Floor The service users admitted to the home who fall within category DE, DE(E) or dual disability DE/PD, DE(E)/PD(E) may only be accommodated on the first floor. Maximum number of service users accommodated on the first floor shall not exceed 30. Maximum number of service users accommodated on the ground floor shall not exceed 24. 7. 8. Date of last inspection Brief Description of the Service: The fees for 2006/07 are £319-£650 per week. The most recent inspection report can be found in the reception area. The Rowans is a care home providing personal care and accommodation for up to fifty-four older people, which includes older people who have a physical disability and dementia. The home is owned by the Southern Cross group of care homes, who own other care homes in Leicestershire. The home is located close to the town centre of Coalville, close to shops, pubs, the post office and other amenities. The home is easily accessible by private or public transport. The home is a purpose built two-storey building with level entry access and access to both floors is accessible by use of the passenger lift or stairs. An adequate number of facilities are situated throughout the premise, namely washing, bathing and toilet facilities. The home has fifty-two single bedrooms, two with ensuite facilities and one double bedroom without ensuite facility. The home has a garden to the side and rear of the building which is well maintained and which is accessible to all The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 5 service users residing in the home The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting residents and tracking the care they received through looking at their records, talking with them where possible, and observing staff that provide their care. The inspection was unannounced and took place over 7 hours one Tuesday in September 2006, and was conducted by one inspector as part of the annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms were inspected. Residents’ and staff records were inspected and visitors, residents and staff on duty were spoken with. Other information that was used to inform this report was the pre-inspection information provided by the registered manager, accident and incident reports received since the last inspection as well as the previous inspection report. What the service does well: The residents live in a clean and well-maintained home, where staff support them to take control and make choices over how they spend their day. Staff are well trained and understand the needs of the residents. The food is of good quality and there is a choice that meets the dietary needs of all residents. Visitors are made to feel welcome and are encouraged to be an active part of their loved ones life. Activities appropriate to the needs of residents are offered during the week and residents who were spoken with said that there was enough happening to keep them occupied. The environment in the ‘Dementia House’ is based on up to date research on effective environments fro people with dementia. The resident or their relative is asked when they come into the home what their favourite colour is and the door to their bedroom is painted a different colour . There are various sitting points along the corridor for residents to sit and each corridor is named after a street. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Although work has been done on care plans they still lack personal detail about the resident and are more general in nature making general statements of well being rather than how this is to be achieved. The Registered Person must ensure that care plans are detailed and personal to the individual. There is no evidence that residents or their representatives are involved in the creation or review of care plans. The Registered Person must ensure that where practicable residents are involved in the creation and review of care plans. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 8 It is recommended that recording of choice and what times residents want to get up and go to bed are included in the care plans to ensure that they have full control over their daily life. Residents did feel able to complain; however the recording of complaints needs to improve to ensure that they are fully recorded in line with regulations. Although most residents said that they felt safe it would appear that some staff may not fully understand what their role is and training should be given to prevent possible abuse. It was also clear from records that the manager was not recognising resident assault on resident as abuse and not forwarding this to social services for advice. The Registered Person must ensure that local safe guarding adult procedures are followed. It is recommended that 50 of staff are trained to NVQ level 2 standard to ensure that residents are in safe hands at all times. Currently there is no registered manager in post. Southern Cross are recruiting but the Registered Person must ensure that a registered manager is in post as the care Standards Act 2000 states it is an offence to manage a care home without being registered. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 9 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 Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 and 6 Quality in this outcome area is good. Residents do not move into the home without their needs being assessed and assured that they will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were viewed as part of this inspection and each contained an assessment either by someone from the home or a social worker prior to admission. The assessment carried out by the home covered all aspects of daily living and was used to a limited extent to inform and create the care plan. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 11 A recommendation was made at the last inspection to involve representatives in the assessment process. It was clear from discussions with the acting manager that steps towards this process have begun. An immediate requirement at the last inspection was made regarding ensuring that an identified resident met the conditions of registration; this was completed during the last inspection. The service does not provide intermediate care. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. Individual plans address needs and risks but they are not detailed to the residents’ preferences and residents or their representatives are not always involved in their review or creation. Medication is handled according to the homes policies and procedures to protect residents and residents are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspectors comments made at the last inspection regarding care plans lacking detail are still relevant. Although each resident has a care plan, it does not specify in any detail residents likes or dislikes, their preference for how they want their care to be delivered. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 13 It is strongly recommended that the Registered Person ensure that all care plans are written in detail to show residents preferences and how staff are to meet identified needs. All residents spoken with said that were aware they had a care plan but had not asked to see it and a visitor spoken with said that he had not been involved in creating the care plan or any reviews. In the pre inspection resident survey comments were positive about the care residents received including the medical support. A requirement was made at the last inspection to ensure that care plans identified where residents had specific health care needs from evidence seen on care plans this has been met. There was some evidence that positive practice was happening, the current acting manager is trying to introduce life history books for residents and evidence was seen that photographs of residents at different important life events were being used to help develop staff’s understanding of the individual. There was little evidence that residents or their representatives were involved in creating or reviewing care plans. The Registered Person must ensure that where practicable that either the resident or their representative are involved in creating and reviewing care plans. There was evidence in plans that good practice was taking place regarding prevention of pressure sores. Care plans showed what action staff had taken in ensuring pressure sores either did not develop if risk assessed as being at risk or if a resident came to the home from hospital with a sore that they were monitored and appropriate care was given to reduce the risk, district nurses were involved where necessary and appropriate equipment such as mattresses and pressure cushions were in evidence again minimising risk. All plans viewed showed that risk assessments were carried out to support them in minimising risk to residents. A requirement was made at the last inspection regarding ensuring that residents with high dependency levels have their care needs met within the home and with district nursing support. From evidence seen on the care plans viewed this requirement has been met. Records showed where residents had lost weight that this was being followed up with referrals to the GP and Dietician, with supplements available to those who needed them. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 14 Medication practice was observed and staff were seen to follow the home’s procedure. The acting manager had introduced a system whereby the staff member who was administering that day wore a tabard that identified what they were doing and that they were not to be disturbed to minimise the risk of medication being given to someone else in error. Good practice was noted in that they had sample signatures for all staff who administered medication and photographs of all residents in the medication administration records, which staff referred to when they administered the medication. In discussion with staff it was clear only trained staff administer medication ensuring that residents are not placed at risk by poor practice. A requirement was made at the last inspection regarding administering medication correctly from evidence seen this requirement is met. All records observed were correct and Controlled drugs medication was checked at the end of each shift to ensure that it was always correct. Staff were observed throughout the day interacting with residents in a positive manner, residents spoken with said that staff were kind and helpful. Although one resident said that staff do not knock before entering the bedroom. This was not observed at all during the day and staff spoken with said that as part of their induction they were instructed on ensuring they knock before entering a bedroom to ensure residents’ privacy and dignity. Residents were clean and well groomed and staff spoken with said that they ensured residents were able to choose their own clothes and those residents who had dementia were supported within their abilities to make choices. This all supports residents’ privacy and dignity. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Residents find the lifestyle meets their expectations and preferences and satisfies their social and cultural needs. Residents are supported to maintain contact with family and friends and are able to exercise choice over their lives. Residents receive wholesome and balanced meals in pleasing surroundings at times convenient to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made at the last inspection to record residents wishes and felling regarding their care particularly in regard to getting up and going to bed. This process has started but must be completed. Residents spoken with commented’ ‘I can go to bed when I want and get up when I want’. However one resident commented that, The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 16 ‘When I ask a certain member of staff to take me to bed she won’t’. This matter was discussed with the acting manager who followed it up to ascertain what the circumstances were. Staff spoken with said that they would go to a resident and ask if they wanted to get up and if they didn’t they would go back later to check they were all right. Although it is not formally recorded in care plans staff are ensuring that residents are able to have control over their lives within the home. It is therefore recommended that the acting manager continue to ensure care plans and diary notes record where residents are supported to make choices and have control over their lives. Where residents have specific cultural needs staff were aware of how to support residents and ensure they were met. Residents spoken with said that they were involved in a variety of activities ad during the inspection staff were observed in involving residents with a different activities including a sing along. Activities were also tailored to the needs and abilities of residents ensuring that all residents were able to participate and gain from the activity. Information was available on notice boards about activities and it also urged families to become involved in any activity they wanted to. Information about activities was also available in pictorial form ensuring residents who may be confused or have lost the ability to read were given the same information. Comments made by residents were, ‘I watch films play skittles, do crosswords, play bingo, there’s enough to keep me occupied’. ‘There is always something to do, I can read a book or use my computer, there was a film this afternoon if I wanted to go’. Staff were observed checking on residents who were confined to bed and sat talking with then to ensure that they do not become isolated, this was recorded in their care plans and in diary notes. This is good practice. Visitors were seen throughout the day and those spoken with said that they were made to feel welcome and could visit any time they wanted to. Some visitors said that they came every day and staff were helpful and polite. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 17 A recommendation was made at the last inspection regarding providing information about advocate services for residents. Evidence was seen during the inspection that this information is now available. The midday meal was observed and appeared appetising and nutritious, residents commented that, ‘There is always plenty of food and if I don’t like something I can have a choice’. ‘The food is good and there is a choice for both main meal and pudding’. In discussion with the cook it was clear she understood the dietary needs of residents and how to ensure that people who had diabetes or needed a soft diet should be supported. A requirement was set at the last inspection to ensure that sufficient staff are on duty to assist with resident at meal times. Staff were seen to provide assistance in a discreet manner ensuring that residents received appropriate help to eat their meal. Therefore this requirement is met. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. Residents and their representatives feel able to complain and are confident that it would be dealt with however recording of complaints does not always follow the homes procedure. Residents are not always protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has received no complaints regarding this service since the last inspection. According to the pre inspection information the home has received four complaints none of which were substantiated and all dealt with in 28 days as per the homes procedure on complaints. However in looking at the information on complaints a complaints was made by a relative that was still pending and had not been logged in the system and did not show that anything had been done to investigate it despite the date it was received being several weeks prior to the date of the inspection. In discussion with the acting manager it was clear that he had followed procedure and sent the complaint to his Operational Manager who had sent a ‘holding letter’ whilst The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 19 it was being investigated, however a copy of this letter was not on file to show what action had been taken. The Registered Person must ensure that a record of action taken with complaints is maintained within the home. Residents spoken with and from pre inspection residents’ surveys it was clear that all knew who to speak to if they had a concern or complaint. Residents said that they felt confident that any concerns would be dealt with. Visitors spoken with said that they would speak to the acting manager if they had a problem but had never had a problem. Staff spoken with also understood how to support residents if they wanted to make a complaint and were clear that they took complaint to the acting manager. Residents spoken with said that, ‘Staff treat me with respect they don’t shout and I feel safe’. However one resident did comment, ‘******** does argue with me and won’t help me’. This was reported to the acting manager who said he would investigate this and speak to the residents in question. Whilst checking incident forms it was noted that one incident referred to a resident who was bruised after being hit/pushed by another resident. It is strongly recommended that where such incidents happen that the manager follow adult protection procedures and notify social services so such matters can be monitored and all residents fully protected. Three staff members were spoken with and all had a very good understanding of what was abuse and what their responsibilities were if they were concerned a resident was being abuses including taking the matter outside the home through the whistle blowing policy. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Residents live in a clean and well-maintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was generally well maintained and there was a programme of routine maintenance provided evidence for this. The grounds were kept tidy and enabled residents to have access to sunlight in better weather. Evidence was seen of recent visits from the local fire service and environmental health department and the home currently complies with their requirements. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 21 Residents spoken with said that their bedrooms were kept clean and that they were always tidy and well maintained. The home was generally clean, however it was noted in some areas that there was a faint odour of urine. The manager said this a persistent problem and that they have tried shampooing the carpet but it has not resolved the problem. The aim now is to replace the affected carpet as part of the ongoing renewal and maintenance of the building. The upstairs of the home is a dedicated area for residents with dementia. This has been redecorated to incorporate up to date research on environments for people with dementia. Each residents’ door is painted their favourite colour, a visitor spoken with said that they were asked what their relatives favourite colour so the door could be painted before they moved in. Each corridor is named as a street and there are benches at various points for residents to rest on. The laundry was sited so as to ensure that soiled laundry was not carried through areas where food is stored, prepared, cooked or eaten and does not intrude on residents. The floor and walls are impermeable and ensures that they can be readily cleaned should they need to be. There are sluicing facilities in the home as well as on the washing machine and good infection control is practiced minimising the risk of infection to residents. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Residents’ needs are met by the number and skills mix of staff and they are trained to do their job. Recruitment practices are good and protect residents from potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was set at the last inspection to ensure sufficient trained staff were working in the Dementia Unit to meet the needs of residents. From observations made on the day of the inspection and from discussion with staff as well as from pre inspection information this requirement is met. Staff spoken with confirmed that they had access to training including NVQ courses. Currently the home does not have 50 of care staff trained to NVQ level 2. The Registered Person must ensure that sufficient staff are placed on NVQ training to meet this target. Recruitment practices are of a good standard and staff files were viewed to show that POVA First checks are made followed by Criminal Records Bureau checks staff spoken with confirmed that they did not start work until all The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 23 references and checks were complete. This was confirmed by the documentation on staff files. Evidence from staff files showed that staff received induction training to a good standard that covered all the areas that staff needed to carry out their role as carer. Staff spoken with said that training was encouraged and regular updates for mandatory training took place. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. There is currently no registered manage in post. The home is run in the best interest of the residents. Their financial interests are protected and their health, safety and welfare are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is currently no registered manager for this home and Southern Cross are currently recruiting to the post. The deputy manager is acting up as manager. From discussion with the acting manager throughout the inspection it was clear he was resident focused and works to improve the quality of life for the residents. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 25 The Registered Person must ensure that the new manager is registered with the Commission as soon as possible. During the course of the inspection the Operational Manager was present carrying out a monthly review of the home copies of which are sent to the Commission. Southern Cross also has a resident survey that it carries out at regular intervals to ensure that residents are happy with the service they are receiving. Residents monies are maintained safely with records kept of transaction and these are signed and countersigned. Residents are therefore protected from financial abuse. Evidence was seen that appropriate mandatory training was carried out for all staff including regular updates. Records showed that appropriate records were kept to maintain the safety of food in the kitchen. Two items were found in the store cupboard that should have been kept in the fridge after opening and they were not labelled correctly. However all items in the fridge were labelled and dated as to when they needed to be used. Records were seen that showed that equipment was maintained and that health and safety of service users was supported. Records were seen of regular fire training and fire drills. There was evidence that regular checks were being carried out on bed rails for residents, however there was evidence that the maintenance man had discovered and error, reported this but no action was taken for several months. The Operations Manger also noted this and dealt with this during the inspection and left instructions that all such information should not only be passed through to the manager but also to her. As this was dealt with appropriately during the inspection a requirement will not be made. A requirement was made at the last inspection regarding ensuring that staff carried out correct moving and handling techniques. Evidence was seen that all staff have received up to date training in this area and so the requirement is met. A recommendation was made at the last inspection to record the outcome of all incidents and accidents. Evidence was seen on accident forms that this was being done. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 26 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15(2) (b)(c)(d) Requirement The Registered Person shall keep the residents’ plan under review; and where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the resident or a representative of his, revise the residents’ plan; and notify the resident of any revision. The Registered Person shall maintain in the care home the records specified in Schedule 4. A record of all complaints made by residents or representatives or relatives of relatives or by persons working at the care home about the operation of the care home, and the action taken by the registered person in respect of any such complaint. The Registered Person shall make arrangements, by training staff or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. Any person who carries on or DS0000039579.V327250.R01.S.doc Timescale for action 01/04/07 2 OP16 17(2) Sch 4 01/04/07 3 OP18 13(6) 01/04/07 4 OP31 CSA 2000 01/05/07 Page 28 The Rowans Care Home Version 5.2 11(1) manages an establishment without being registered shall be guilty of an offence. The Registered Person must ensure that a manager is appointed and registered. 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 4 Refer to Standard OP7 OP12 OP18 OP28 Good Practice Recommendations Care plans should provide detail of how the individual residents care is to be delivered. Care should detail what time residents usually want to get up and go to bed. Where incidents involve a resident assaulting another resident this should be passed to the local social services to follow up. The Registered Person should ensure that a minimum of 50 of staff are trained to NVQ level 2 standard. The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Rowans Care Home DS0000039579.V327250.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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