Care Home: Rosecroft

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What the care home does well Prospective residents are given information about the home to help them decides whether it is a suitable place for them to live. The home provides a relaxed atmosphere for people who live there. The assistant manager is committed to improving the systems in the home so that progress can be made towards meeting all the standards. People spoken with said that most of the staff are kind and that they get on with them well. Most of the staff have worked in the home for some time and so people benefit from receiving care from people they know well and who understand their needs. The home assists people to stay in familiar surroundings if their health needs increase. People are encouraged and supported to remain as independent as possible and to maintain contact with relatives. Comments we received from residents include; “Good food, good staff.” “Good caring environment.” “Staff very helpful.” Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 “If I need help I get it.” What has improved since the last inspection? The assistant manager has worked hard to improve pre-admission assessments, care plans and risk assessments. Care plans now include photographs of residents to assist new staff in recognising people. Some areas of the inside and outside of the home have been redecorated. New carpets have been fitted in some bedrooms and communal areas. Policies and procedures have been put into place to make sure that people’s finances are protected. The assistant manager has improved the staff training records so it is easy to see who has received what training and when updates are due. A training plan has been devised and all staff have now received mandatory training. Problems with the lift that the home was experiencing at the last inspection have now been resolved, allowing residents access to all areas of the home. A new washing machine with a sluice cycle has been purchased. The laundry and hand washing facilities have been improved. Substances hazardous to health are now being kept in lockable storage to minimise risk. What the care home could do better: The handling, storage and administration of medicines need to be improved to protect residents. The activity programme could be improved to encourage more people to join in. While some residents are happy with the activities on offer, others would like to go out more, and say that they feel lonely and isolated. The environment is in need of some improvement, especially the upstairs bathroom. The lounge is cluttered and confidential information is left out in breach of people’s right to privacy and confidentiality. The home also needs to ensure that any person who has regular contact with residents in the home and who is acting in the role of a member of staff or volunteer should have the appropriate checks undertaken to ensure that unnecessary risks to the health or safety of service users are minimised.RosecroftDS0000014687.V376946.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Rosecroft 8 Cross Road Southwick West Sussex BN42 4HE Lead Inspector Jo Hartley Key Unannounced Inspection 4th August 2009 10:30 DS0000014687.V376946.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosecroft Address 8 Cross Road Southwick West Sussex BN42 4HE 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) 01273 597326 Mr D R Clark Mr D R Clark Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (1) of places Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total of 19 persons at any one time, one of whom is in the category of Physical Disability, aged 60-65 years. 12th August 2008 Date of last inspection Brief Description of the Service: Rosecroft is a care home that provides personal care and support for up to nineteen older people. The home is located in Southwick, opposite the village green. Local shops and other community facilities are within walking distance. Communal areas include: a lounge that is also used as a dining room. Private accommodation consists of seventeen single bedrooms and one double bedroom. Mr Dennis Clark is the provider and registered manager. An assistant manager is responsible for the day-to-day care provided in the home. Current fees start at £400 depending on need. Rosecroft DS0000014687.V376946.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 One Star. This means that the people who use this service experience adequate outcomes. Seven of the eight requirements that were made at the last inspection have been addressed. Four further requirements have been made following the site visit. Annie Taggart, Regulatory Inspector, accompanied the lead inspector on the site visit for this key unannounced inspection. The inspection lasted six hours. Mr Clark and the assistant manager assisted with the inspection. The information and paperwork we required was available. The assistant manager returned an Annual Quality Assurance Assessment form (AQAA) that provided a lot of information about the service and the care provided; the AQAA was used to help in the planning of the inspection. Surveys about the service were received from eleven people living in the home, three staff and three social and healthcare professionals. During the visit we examined documents that included; the records for six people who live at the home, recruitment and training records for six staff, the complaints records, medication records and storage, some quality assurance feedback and other relevant information. Staff and residents of the home also assisted us during the inspection. What the service does well: Prospective residents are given information about the home to help them decides whether it is a suitable place for them to live. The home provides a relaxed atmosphere for people who live there. The assistant manager is committed to improving the systems in the home so that progress can be made towards meeting all the standards. People spoken with said that most of the staff are kind and that they get on with them well. Most of the staff have worked in the home for some time and so people benefit from receiving care from people they know well and who understand their needs. The home assists people to stay in familiar surroundings if their health needs increase. People are encouraged and supported to remain as independent as possible and to maintain contact with relatives. Comments we received from residents include; “Good food, good staff.” “Good caring environment.” “Staff very helpful.” Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 6 “If I need help I get it.” What has improved since the last inspection? What they could do better: The handling, storage and administration of medicines need to be improved to protect residents. The activity programme could be improved to encourage more people to join in. While some residents are happy with the activities on offer, others would like to go out more, and say that they feel lonely and isolated. The environment is in need of some improvement, especially the upstairs bathroom. The lounge is cluttered and confidential information is left out in breach of people’s right to privacy and confidentiality. The home also needs to ensure that any person who has regular contact with residents in the home and who is acting in the role of a member of staff or volunteer should have the appropriate checks undertaken to ensure that unnecessary risks to the health or safety of service users are minimised. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 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 Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs assessed before moving into the home to ensure that the home can provide a service for them. Rosecroft does not provide intermediate care; therefore standard six does not apply to this home. EVIDENCE: Prospective residents are provided with information about the home to help them make a decision about whether it is the right place for them to live. We saw that every resident has a copy of the Service User Guide in their bedroom. We looked at the records of six residents and saw that social workers and relevant health care professionals had provided assessments before people moved to the home. At the last inspection it was found that there was no Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 10 evidence to show how a decision had been made by the home that they could meet the persons needs or that the person themselves had been involved in this process. A requirement was made regarding this. At this inspection we found that the assistant manager has developed a format so that an assessment can be carried out before a decision is made about the person moving in. Prospective residents and their relatives are involved in this process. The requirement has now been met. We saw that residents are given a contract that shows the terms and conditions of the home when they move in. Most of the contracts that we saw were signed by the resident. Four had been drawn up and awaiting signatures. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, personal and social care needs are set out in an individual plan of care. People’s health care needs are met. Some of the practices regarding medication put people at risk. Privacy and dignity are respected by staff. EVIDENCE: We looked at care plans for six residents. The assistant manager hand writes all care plans. They were clearly written and set out in detail how the home will meet individual needs. Evidence was seen that they are reviewed and updated regularly. The care plans included information about personal hygiene, communication, physical abilities and general health. The background information was detailed and provided guidance for staff about the way to support people. There was an emphasis on supporting people with their independence, focussing on what the Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 12 resident is able to do for themselves as well as what assistance they need. For one resident who experiences anxiety there was guidance for staff on how to reassure and calm her. Service users and relatives had been involved in the care planning and staff spoken with said they understand people’s needs. At the last inspection there were no photographs on care plans. These are now in place. We received three surveys from staff who said they are kept up to date with residents’ changing needs. Environmental and individual risk assessments are in place for areas inside and outside the home, falls, pressure areas and mobility. For residents who smoke there are risk assessments for their personal risk and the risk to staff and other residents. The deputy manager also carries out monthly hazard checks of all rooms. People’s health care needs are recorded and people are supported to attend medical appointments as required. Contact with medical professionals such as GPs, continence advisors, chiropodists, dentists and district nurses are recorded. Residents who responded to our surveys said that their healthcare needs are met. Residents that spoke with us during the visit said that the home calls a GP to see them if they wish. One person chooses to stay in bed all day. He does not accept assistance with personal care and eats his own choice of food. He told us that this is his choice. We saw a letter in his care plan that his GP and care manager are aware of this. His care manager has also written a letter to say that this person’s condition has improved since coming to Rosecroft. The staff who administer medication have all attended training in the administration of medication. The recording system and storage facilities were seen. Medication is kept in a small locked cupboard. Medications not in blister packs were in locked boxes. There is no storage facility for controlled medication however no controlled drugs have been prescribed at present. If this situation changes the home must ensure that a controlled drug cupboard that complies with the current legislation is supplied and fitted. When we arrived at the home four boxes of newly delivered medicines were seen on the side in the dining room unattended. We also found a tablet on the floor of a resident’s room. In another resident’s room we saw two prescribed creams that had the name and directions of use removed. One of these creams was not recorded on the resident’s medication administration record. All of these can provide a risk to residents’ safety. A requirement has been made regarding this. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 13 Residents who took part in the inspection said that staff treat them with respect. Staff were observed being sensitive and patient in the way they were providing care. People living at the home looked well kept and nicely dressed, areas such as hair wash, bath and nail care were being attended to. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people find the lifestyle they experience in the home matches their expectations, however two people said they feel lonely and isolated. People are supported to maintain contact with relatives and friends. People exercise choice and control over their lives. People are provided with a balanced and nutritious diet. EVIDENCE: There is a very limited activities programme in the home that consists of exercises once a week, occasional day trips, bingo, poetry and reminiscence. We were told by the manager in the Annual Quality Assurance Assessment, (AQAA), that not much enthusiasm has been shown by residents in taking part in activities. The responses to our surveys and discussions with residents during the visit were mixed. Some people said they do not want to take part in activities but two people said they feel isolated and lonely. A comment on a survey from one resident was, “it would be nice to go out.” Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 15 Residents told us that they sometimes helped out in the garden. Two people went out independently on their motor scooters; other people were watching television in the lounge or in their rooms. There is a quiet lounge where games and puzzles are available for people if they wish to use them. People’s hobbies and interests are recorded in their care plans and any participation in activities is recorded. People who live at Rosecroft are supported to maintain contact with relatives and friends. Two people visiting a relative while we were at the home told us that they are always made welcome. People are supported to make some choices in their daily lives. They can get up and go to bed at times they choose, eat their meals where they wish and choose what clothes they wear. There is an emphasis on encouraging people to maintain their independence and there was evidence of this in the care plans. People have a choice of meals available to them. Everyone has a copy of the menu in their room. Three people confirmed to us that they could ask for an alternative meal if they don’t like the one on the menu. On the day of the visit the main meal was sausages and burgers with fresh vegetables. Care staff on duty prepare all the meals. Since the last inspection scales have been purchased by the home so that people can be weighed each month to monitor their wellbeing. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their concerns and complaints will be listened to and acted upon. There are measures in place to protect people from harm. EVIDENCE: The home has a book where concerns and complaints are recorded, progress of each investigation is monitored and the outcome recorded. Nine complaints had been received since the last inspection. People who returned surveys said they know who to speak to if they have a concern and they feel they would be listened to. In the responses to the quality assurance questionnaires that the home gave out to residents some people said that they would feel happy making a complaint to the assistant manager but not to Mr Clark. The home has a copy of the Sussex Multi-Agency Policy and Procedure for Safeguarding Vulnerable Adults. All staff have attended training in the safeguarding of vulnerable adults and the two members of staff who spoke with us understood their responsibilities to report any concerns. We raised a concern with the manager regarding a person who was in the home for the whole duration of our visit, nearly seven hours. This person was seen in two residents’ bedrooms and in the lounge. Mr Clark told us that this person was a friend of the residents concerned. We informed Mr Clark that it Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 17 had been observed that this person was acting like a member of staff or volunteer, for example calming down a person who was agitated, sitting watching television with people all day and going into two residents’ bedrooms. We discussed with Mr Clark that if this person has such a prominent role within the home they should be designated as a volunteer and have a Criminal Records Bureau check to protect everyone within the home. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some areas of the home are not safe and well maintained. The laundry facilities have been improved. EVIDENCE: The outside of the home has recently been painted in bright colours. The hall has also been redecorated. New carpets have been fitted in some bedrooms and communal areas of the home. There are areas of the home, particularly the bathrooms that are in need of updating. In an upstairs bathroom the sink and bath were heavily stained with lime scale, the window was not restricted and the light was not working. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 19 Residents’ bedrooms are basic and some furniture is old and shabby. In two bedrooms we found that the toilet seats were broken, and there was a strong smell of urine in one resident’s bathroom. In another bedroom the carpet was coming away from the floor and may pose a risk of tripping to the resident. When we arrived at 10.30 in the morning the home was not very clean and tidy. By lunchtime the lounge/dining room had still not been cleaned or vacuumed. We were told that a cleaner works part time in the home and comes in during the afternoons. However, during the morning care staff were cleaning and making beds. The lounge was seen to be cluttered with paperwork and boxes. Two out of the three staff who returned surveys said that the home could be tidier. One comment from staff on what the home could do better was, “Tidying up of the lounge, lots of clutter, paperwork could be put away making it look more respectable.” Part of the lounge is being used as an office. Confidential records were left out on the side where anyone entering the home could read them. The manager must make sure that confidential documents are stored in a lockable facility and that disruption to people living in the home is kept to a minimum. A requirement has been made regarding this. At the last inspection it was found that the laundry room was in need of refurbishment and that the hand washing facilities for staff were not accessible because a washing machine had been fitted in front of it. It was also found that bleach and other hazardous material had not been locked away and the cupboard for storage of these materials was not lockable. These have now been addressed and the requirements have been met. Radiator covers have been fitted to radiators in most people’s rooms to prevent the risk of burns. Several radiators in the hallways, communal areas and bathrooms are not protected to ensure that the surface temperature is kept at a safe level. Mr Clark told us that these radiators are not used in cold weather; we were not able to substantiate this as the weather was warm on the day of our visit and there was no need for the radiators to be on. Two relatives have told us that the home can be cold in the winter. At the last inspection a requirement was made that the surface temperature of radiators that are used in cold weather should be at a safe temperature that protects people from the risk of burns. This requirement is being repeated. The rear garden is attractive and well maintained. People said they sit out there when the weather is good. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s care needs are met by the numbers of staff on duty, however some concerns have been raised about care staff also undertaking domestic and catering duties as well. The home’s recruitment policy and procedure protect people. Staff have received training so that they have the knowledge and skills to do their job. EVIDENCE: When we arrived at the home the manger, two care staff and a volunteer were on duty. The assistant manager came on duty shortly after we arrived. Mr Clark told us that two staff had phoned in sick for the morning shift. In the surveys that we received two members of staff said there are usually enough staff on duty to meet people’s needs and one said there always is. Four residents told us that staff are always available when they are needed, six said they usually are and one said they sometimes are. Care staff are also responsible for cooking and cleaning the home. We received a comment from a social care professional who said, “I do worry about staffing levels, as care staff appear to also undertake domestic and catering tasks.” We were told that the home employs an afternoon cleaner. During the visit we Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 21 witnessed care staff doing domestic chores and a cleaner also came into the home after lunch. We looked at six staff files and found that they all contained application forms, Criminal Record Bureau Checks and two written references. The assistant manager has updated and reorganised the staff training files. It is now easy to see which staff have received what training and when updates are due. In the six files seen, all of the staff had attended mandatory training, and had attended updates for health and safety, moving and handling and infection control. Some staff have received training in dementia awareness. We were told that all of the staff team except one have a level two National Vocational Qualification in care. Two residents told us that some staff could be abrupt in their manner. We fed this back to Mr Clark who was able to identify a staff member but said it was just her way and that she had been spoken to about this. Other comments we received from residents about staff include; “Good caring place, staff very helpful.” “I am satisfied with the care.” “If I need help I get it.” “Nice helpers.” Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The owner and manager, Mr Clark, has obtained the NVQ level four in care and the Registered Manager’s Award. He runs the home with the assistant manager who has also achieved the Registered Manager’s Award. The manager and assistant manager have many years of experience in providing care for older people. At the last inspection the assistant manager said that the home would be purchasing a computer to make the running of the service more efficient. Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 23 This has not yet happened but all documents are hand written and easy to read. A quality assurance process had been carried out and we were able to see the questionnaires from service users and some relatives. The home is waiting for more relative’s surveys to be returned. Some people said that they would feel happy making a complaint to the assistant manager but not to Mr Clark. Most people said they were happy with the service being provided. Some people reported that the meals were monotonous. This had been responded to and a letter was in each person’s bedroom regarding this The home does not take responsibility for anyone’s finances; family members or solicitors carry out this task. Staff or volunteers do assist people with some financial transactions and buying small items. At the last inspection there was no clear policy or guidance for staff and no system for ensuring that these transactions are recorded and receipts obtained. This has now been addressed and a policy is in place to protect residents. The AQAA showed that equipment is maintained and serviced as required. At the last inspection the home was experiencing intermittent problems with the lift and a requirement was made regarding this. These problems have now been resolved and the requirement met. At the last inspection staff said they had been provided with training; however there was no evidence to show that all staff had attended the required health and safety training. Since then the assistant manager has put together a training file that clearly shows that staff have now received this training. A record is kept of accidents and incidents in the home and these are monitored by the assistant manager. However, the home has not been reporting these to The Commission. A requirement has been made regarding this. As described earlier in this report the home needs to ensure that confidential records are securely stored. Rosecroft DS0000014687.V376946.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 13 Requirement The registered person must protect people from the risks associated with the unsafe use and management of medicines. Medicines must not be left unattended. Medicines must only be used for those for whom they have been prescribed. Any person who has regular contact with residents in the home and who is acting in the role of a member of staff or volunteer should have the appropriate checks undertaken to ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Records must be kept secure to protect residents’ confidentiality. The registered person must notify the Commission of any incidents that are set out in Regulation 37 of The Care Homes Regulations 2001. The surface temperatures of all radiators that are used in cold weather should be kept at a temperature that protects people DS0000014687.V376946.R01.S.doc Timescale for action 11/08/09 2 OP18 13 (4) (c) 04/09/09 3. 4. OP37 OP38 17 (1) (b) 37 04/09/09 06/08/09 5. OP38 13 04/10/09 Rosecroft Version 5.2 Page 26 from the risk of burns. Previous timescale of 31/10/08. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosecroft DS0000014687.V376946.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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