Care Home: Rookwood Residential Care Home

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What the care home does well Rookwood is a large house providing comfortable accommodation for the residents. The management of the home has been very stable, as too have some of the people who have lived there for a number of years. Both the staff and manager have a good understanding of the needs of people and where needed will seek out the support and advice from health professionals making sure that the health and well-being of people is maintained. People at the home and staff made the inspector very welcome and were happy to talk. One person said; `I`ve settled very well`, `have everything I need` and `I`m comfortable`. Other comments received on the surveys confirmed that the staff always treated them well, that they were able to do what they choose, that they were listened too and generally knew what to do and who to speak with if they had any concerns. What has improved since the last inspection? The Manager has addressed the requirements made during the last visit in relation to medication, staff recruitment and health and safety checks. As already stated the home continues to offer the stability needed for people who live there helping them to maintain their mental health and well-being. What the care home could do better: Risk assessments must be completed in all areas of potential risk identifying the action to be taken to minimise such risk ensuring people are safe. All staff administering medication must receive appropriate training ensuring practice is safe and people are not placed at risk. All staff must receive training in relation to the local authority safeguarding procedure so that they are aware of the procedure to follow should an allegation be made ensuring people are protected. The manager must develop an annual training plan ensuring all staff receive the necessary training and refreshers required ensuring they have the skills and knowledge needed to meet the needs of people living at the home. A formal system of staff supervision should be developed along with records to evidence that staff receive the support and direction needed to carry out their role effectively. The manager should carry out competency assessments on staff that administered medication ensuring practice undertaken is safe. Evidence of this should be placed on file. A system of reviewing the service should be developed including feedback sought from people at the home and other interested parties. Findings should then be provided within a report and a copy forwarded to us and others involved with the home. On completion of the boiler installation the manager must ensure that an up to date gas safety certificate is placed on file. CARE HOME ADULTS 18-65 Rookwood Residential Care Home 219 Walmersley Road Bury Lancs BL9 5DF Lead Inspector Lucy Burgess Unannounced Inspection 30 September 2008 11:30 th Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 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 Rookwood Residential Care Home DS0000008425.V371487.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 Adults 18-65. 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. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rookwood Residential Care Home Address 219 Walmersley Road Bury Lancs BL9 5DF 0161 761 7952 0161 761 7952 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) Mrs Anna Geraldine Ellis Mr Colin Bruce Ellis Mrs Collette Mary Richmond Care Home 17 Category(ies) of Learning disability (17), Mental disorder, registration, with number excluding learning disability or dementia (17) of places Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD (maximum number of places: 17) Learning disability - Code LD MD (maximum number of places: 17) The maximum number of service users who can be accommodated is: 17 Date of last inspection 15th November 2006 Brief Description of the Service: Rookwood provides residential care and support for up to seventeen people who are recovering from a mental illness. The home is owned by Mrs A Ellis and managed by Mrs C Richmond. Fees at the home are £400.00 per week. The property is a large converted house that is sited on a main road about a mile from Bury town centre. Accommodation is on three levels and comprises of three lounges, a dining room, eleven single bedrooms and 3 double rooms. There are also four bathrooms and eight separate toilets. The home is spacious, homely and well maintained. Service users have access to local shops, pubs and other amenities situated nearby and there is easy access to bus services. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was a key inspection, which included a site visit and took place over one day for a period of 6 hours. The service did not know that the inspector was going to visit. As part of the inspection process the provider’s are asked to complete a selfassessment survey information document (Annual Quality Assurance Assessment). This was sent to the agency before the inspection and had been completed by the registered manager and returned to us prior to the site visit. During the visit we spent time looking at care records as well as information about the staff and health and safety. We also looked round the home environment. Other information was gathered from the feedback surveys we sent out. We received completed surveys from 6 people living at the home and 3 staff members. Comments have been added to the report. Discussion and feedback was held with the manager during the visit. What the service does well: Rookwood is a large house providing comfortable accommodation for the residents. The management of the home has been very stable, as too have some of the people who have lived there for a number of years. Both the staff and manager have a good understanding of the needs of people and where needed will seek out the support and advice from health professionals making sure that the health and well-being of people is maintained. People at the home and staff made the inspector very welcome and were happy to talk. One person said; ‘I’ve settled very well’, ‘have everything I need’ and ‘I’m comfortable’. Other comments received on the surveys confirmed that the staff always treated them well, that they were able to do what they choose, that they were listened too and generally knew what to do and who to speak with if they had any concerns. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Risk assessments must be completed in all areas of potential risk identifying the action to be taken to minimise such risk ensuring people are safe. All staff administering medication must receive appropriate training ensuring practice is safe and people are not placed at risk. All staff must receive training in relation to the local authority safeguarding procedure so that they are aware of the procedure to follow should an allegation be made ensuring people are protected. The manager must develop an annual training plan ensuring all staff receive the necessary training and refreshers required ensuring they have the skills and knowledge needed to meet the needs of people living at the home. A formal system of staff supervision should be developed along with records to evidence that staff receive the support and direction needed to carry out their role effectively. The manager should carry out competency assessments on staff that administered medication ensuring practice undertaken is safe. Evidence of this should be placed on file. A system of reviewing the service should be developed including feedback sought from people at the home and other interested parties. Findings should then be provided within a report and a copy forwarded to us and others involved with the home. On completion of the boiler installation the manager must ensure that an up to date gas safety certificate is placed on file. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 7 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. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those people who move into the home have their needs fully assessed prior to admission ensuring the placement is suitable and their needs can be met. EVIDENCE: Placements at the home have remained very settled. Since we last visited the home a further permanent placement has been made and another person is currently receiving respite. The local authority funds both of these placements. We looked at what assessment information had been provided. On the first file information included a community care assessment, nursing assessment, risk screening tool and a service specification and agreement. There was also a detailed assessment on the second file. Each of the documents provided very detailed information about the persons health and social history, treatment, support services, medication, as well as people’s support needs and areas of risk. The manager explained that the person currently receiving respite had expressed a wish to move into more independent accommodation. This was being explored with the funding authority, however until such time would remain at the home. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 10 Each of the placements continue to be reviewed following the initial 6 week period to ensure the suitability of placement. Information gathered at the assessment process is then used to inform the development of a care plan. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans show that people are supported in a way in which they choose however risk assessments need to be expanded upon so that areas of potential risk are minimised and people are supported safely. EVIDENCE: Information recorded on the care plans varied depending on the support needs of each person. Records were looked for two people who had move into the home following our last visit. We found that information is held in two files. One file contains information about the persons assessed needs, a copy of their contract agreement, financial information and other relevant correspondence. The second file is a ‘working file’ and includes the care plan, risk assessments, record of health appointments and daily reports. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 12 Each of the files had a risk assessment document, which identifies areas of concern in their mental health, environment, person safety etc. However we found that whilst issues had been identified there was no guidance in relation to how this could be minimised. The manager explained to use what support was offered by staff making sure that people were supported safely. This information needs to be recorded. We noted on the first file that this person had recently been diagnosed with epilepsy however there was no information found on the care plan nor had a risk assessment been completed. Other issues were also identified with regards to their diet and nutrition. The manager was advised to include these within the risk assessments ensuring staff are clear about their responsibilities should concerns arise. On the second file information also needed expanding upon. Areas of risk included concerns about the person’s behaviour, levels of agitation, aggression and safety. Again the assessment did not identify how this was to be minimised ensuring peoples safety. People are encouraged to be involved in the development of their plan. The home has a system of reviewing plans on a 6 monthly basis and any changes are noted. Where additional needs have been identified plans would be reviewed more frequently. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines continue to promote people’s independence allowing them to follow a lifestyle of their choosing. EVIDENCE: Daily routines reflect the personal choices and preferences of people. Staff encourage people to access the wider community enabling them to learn new skills and develop other friendships. Whilst some people continue to attend local colleges and centre’s others prefer a more relaxed routine spending the majority of time at home relaxing and chatting or watching TV. We were told that two people had joined an advocacy group and had gone on an overnight trip with the group. People have access to all local amenities such as the local shops and pubs. Some individuals use their bus pass allowing them to travel independently within the local and wider community. People are able to come and go as Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 14 they choose. Each person has been provided with a key to their own room however front doors keys are not routinely offered, as staff are available at any time. Contact with family and friends are maintained with visits taking place both to and away from the home. This may involve people visiting relatives for the weekend or holidays. A number of people were seen relaxing in the smoking lounge. People appear to enjoy each other’s company and spend time chatting together. Some people completed the feedback surveys and returned them to us. One person said ‘I’ve settled very well’, ‘have everything I need’ and ‘I’m comfortable’. Others confirmed that the staff always treated them well, that they were able to do what they choose, that they were listened too and generally knew what to do and who to speak with if they had any concerns. In relation to meals, the home has a 4 weekly menu. This is currently being updated to include some different meal choices. One person has a vegetarian diet. The manager explained that the same meal choices are offered with a meat substitute. Alternatives are also offered to those people who are diabetic. All meals are served in the dining room with everyone dining together. A lighter lunch is served offering either a hot or cold meal. The main meal is served at teatime along with a desert. Suppers are also provided. In relation to drinks, people do not have open access to the kitchen to make hot drinks however are able to make a cold drink. This is due to potential hazards. Hot drinks are provided by staff at regular intervals throughout the day and those people who are able to have a kettle in their room are able to make drinks whenever they choose. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective support is offered to people ensuring their health and well-being is consistently met. EVIDENCE: People living at the home are supported and encouraged by staff in meeting their personal health care needs. The level of support required varies depending on the specific needs and wishes of each person and is detailed in their care plan. Other support is provided from the local mental health teams with regards to people’s emotional health. Some of the people continue to have formal reviews in line with the discharge programme (CPA). This is held with their psychiatrist and community nurse. The manager said that they have good working relationships with them and will seek out additional support and advice should this be necessary. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 16 All people have access to other health care such as dentist, optician, chiropody and diabetic and epilepsy clinics. Appointments are made as and when required. Staff provide support where necessary. Records are completed for all health appointments along with any action required. Other records including peoples weight being monitored. Prompt action is taken to address all issues or concerns identified ensuring the health and well-being of people is not affected. The medication system was examined and found to be safe. Medication is supplied on a monthly basis and records are made to reflect all items brought in to the home as well as those returned to the supplying pharmacist. There were no controlled drugs. The administration records were examined. These too were in good order. Information in relation to homely remedies were also recorded to show what someone had taken. People’s medication is regularly monitored and reviewed during appointments ensuring the stability of their mental health. Medication training is required, particularly for the two new members of staff. Whilst waiting for the appropriate training the manager was advised to carry out an observation of their practice and assess their competency in administering medication ensuring their practice is safe. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place with regards to complaints and protection making sure that people feel listened to and are valued. EVIDENCE: No complaints or concerns have been raised with us or at the home since our last visit. Staff training has been undertaken with regard to adult protection however this does not cover the policy and procedure held by the local authority. The manager has recently applied to the local Training Partnership Group. Once membership has been agreed arrangements will be made for staff to access relevant training including the safeguarding adults course. Arrangements were also looked at with regards to the management of people’s finances. Most of the people manage their own personal allowances however some are offered support from staff with an agreed budget plan having money provided each day. Whilst some records are maintained this is not standard practice. The manager must ensure that individual records are held for each person where money is held on their behalf. Records should evidence a running balance as well as all transactions. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good standard of accommodation is provided offering people comfortable and well-maintained facilities in which to live. EVIDENCE: Rookwood is a large domestic dwelling and provides comfortable accommodation for people living there. Accommodation comprises of 11 single bedrooms and 3 double rooms. None of the rooms have en-suite facilities. There are also 3 lounges, one is a designated smoking area, a separate dining room with the office and laundry in the basement. The home also has 3 bathrooms, 1 shower room and 8 separate toilets, which are accessible throughout the building. The providers ensure that the standard of décor and furnishing are maintained to a good standard. Over the last year each of the bedrooms have been repainted and where necessary new carpets and furniture have been provided. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 19 Each of the lounges have also been painted, a new kitchen has been fitted as well as a new boiler. There is a part time domestic that is available each weekday. Staff also carry out additional tasks such as the laundry. Hygiene standards within the home are good. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures are safe however arrangements in relation to staff training and supervision need to be improved so that they have the knowledge and skills necessary to carry out their role safely. EVIDENCE: Information provided on the AQAA stated that over the last 12 months 4 staff have left employment. This has caused some difficulties for the manager however shifts have been covered by existing staff as well as some recruitment having taken place. The rotas were examined. There are two staff on duty between the hours of 8am and 5pm in addition to the manager and then single cover between 5pm and 10pm. There is also a wake in night staff. The manager and owner provide on call support. Recruitment files were looked at for the two newest members of the team. Information had been gathered with regards to an application form including a detailed employment history, written references, one being from the previous Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 21 employer, copies of identification, a health declaration, Protection of Vulnerable Adults check (POVA) and Criminal Record Checks (CRB). Staff training was also looked at. Over the last year little training has been provided other than courses in equality and diversity and disability awareness. The new staff have also undertaken a 3 day induction programme, which includes all relevant training. The manager explained that an application has recently been submitted to the local Training Partnership Group. Staff have completed a training needs analysis identifying what training they require. Once this has been arranged the manager will book places for staff. As part of the training plan the manager should ensure that this includes medication, safeguarding adults and fire training. National vocational qualifications (NVQ) have also been provided. Of the current 9 staff, 6 staff have achieved level 2, of which, two staff would like to progress to level 3. The manager is to explore funding available for this. We discussed with the manager what arrangements are in place for team meetings and staff supervisions. The manager said that breakfast meetings are held between the staff and the manager each morning as part of the shift handover. Occasional meetings are also held with individual staff members to discuss any specific issues, which may arise, however none of these meetings are recorded. The manager also acknowledged that supervisions sessions do not take place. The manager must make suitable arrangement ensuring staff receives an agreed level of support and that evidence of such meetings can be provided. Comments were also received from staff. Staff felt that they were supported by their manager, that information was shared well between the team, that they had received relevant training and that generally there was enough staff. However one person felt that staffing levels could be improved and that formal arrangements to meet with the manager could be better. The manager is aware that these areas need addressing and is currently recruiting for staff. Action has also been identified with regards to formalising supervision for staff so that they feel supported in carrying out their role. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst there has been some staff turnover the management of the service remains stable. The manager is clear about her role and responsibilities and works hard to ensure that a quality service is provided to those people living at the home. EVIDENCE: Management arrangements within the home have remained unchanged for a long time offering people at the home stability. Both the Provider and Manager have a good awareness and understanding in relation to the needs of people living at the home. Monthly monitoring visits by the provider are not undertaken as she spends time working at the home each week supporting the manager, therefore is actively involved or aware of the day-to-day running of the home. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 23 We discussed with manager arrangements in relation to quality monitoring and reviewing the service. The manager sends out feedback questionnaires however this has yet to be carried out this year. The manager should consider how feedback can be gathered from other people involved with the service such as Doctors, social workers etc. This information should then be used to inform the homes annual development plan showing what areas the home performs well in along with areas they wish to develop further. A copy of the report should be shared with all interested parties as well as us. A sample of records were also looked at with regards to health and safety. An up to date service certificate was in place for 5year electric check, small appliances, fire alarm and equipment and emergency lighting. The home is currently having a new boiler installed. On completion a gas safety certificate should be sought. Further checks are also carried out within the home. These include fire safety checks and the emergency lighting. We were told during the visit that incidents had occurred at the home, which potentially affected the well-being of people at the home. The manager was reminded that information should be reported to us in line with regulation 37 along with the action taken to ensure people are safe. Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 25 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 YA9 Regulation 13(4) Requirement Risk assessments must be completed in all areas of potential risk identifying the action to be taken to minimise such risk ensuring people are safe. Timescale for action 30/11/08 2 YA20 13(2) All staff administering medication 30/12/08 must receive appropriate training ensuring practice is safe and people are not placed at risk. All staff must receive training in relation to the local authority safeguarding procedure so that they are aware of the procedure to follow should an allegation be made ensuring people are protected. The manager must develop an annual training plan ensuring all staff receive the necessary training and refreshers required ensuring they have the skills and knowledge needed to meet the needs of people living at the home. 30/12/08 3 YA23 13(6) 4 YA35 18(1) 30/11/08 Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 26 5 YA36 18(2) A formal system of staff 30/12/08 supervision should be developed along with records to evidence that staff receive the support and direction needed to carry out their role effectively. 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 YA20 Good Practice Recommendations The manager should carry out competency assessments on staff that administered medication ensuring practice undertaken is safe. Evidence of this should be placed on file. The Registered Person must ensure that a system of reviewing the service is developed and feedback sought from other stakeholders involved within the home. Finding should be provided within a report and a copy forwarded to CSCI. On completion of the boiler installation the manager must ensure that an up date gas safety certificate is placed on file. 2 YA39 3 YA42 Rookwood Residential Care Home DS0000008425.V371487.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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