Care Home: Rosetrees

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What the care home does well The home is clean and furnished to a high standard. There are no offensive odours. Residents interviewed are happy with their accommodation and facilities provided. The meals provided are well balanced, varied and those interviewed said they are generally satisfied with these meals. The meals prepared are kosher and in accordance with the Jewish religious laws. The care provided is client centred and effort is being made to address the specific care needs and preferences of residents. Care documentation is comprehensive and care provided is regularly reviewed. The home has a varied and good range of activities which are appropriate for residents. This ensures that residents are provided with social and mental stimulation. A detailed record of activities engaged in is kept. Jewish holy days and festivals are celebrated at the home. Staff are caring and knowledgeable regarding their roles and responsibilities. There is an ongoing programme of training to ensure that staff are able to meet the needs of residents. Relatives and other visitors are made welcome at the home. They are given the opportunity to meet with the managers of the home at regular meetings and are invited to a number of formal social events held at the home. What has improved since the last inspection? A review of the personal care provided for the resident (identified to the manager during the inspection of 25/2/08) had been carried out to ensure that this person`s personal care needs are attended to. Staff had been instructed to treat all residents sensitively and with respect and dignity. Residents and relatives interviewed were able to confirm that they had been well treated. Arrangements were in place to ensure that staff undertake training in all areas identified in the last inspection report. Staffing levels of care staff on the dementia unit had been reviewed to ensure that there is sufficient staff available to care for the needs of residents. Two relatives interviewed were of the opinion that residents in this unit are well cared for and they spoke highly of staff on this unit. The manager had submitted an application for registration to CSCI to become the registered manager of the home. The home had a management plan detailing which senior staff are responsible for the home in the absence of the manager and her deputy. What the care home could do better: The staffing arrangements must be reviewed to ensure that residents are well cared for and concerns made by residents and staff are responded to. The complaint that on some occasions there appeared to be insufficient staff and the call bell was not answered promptly between 5 pm to 8 pm must be investigated. This is to ensure that residents are promptly attended to. The results of the investigation must be forwarded to the CSCI. The home must have appropriate contingency arrangements for ensuring adequate care staff cover when care staff are off sick. This is to ensure that there is adequate staff cover to attend to the needs of residents. Staffing levels of care staff and the deployment of care staff on weekdays and at weekends must be reviewed with staff and residents. This is to ensure that there is adequate staff cover to attend to the needs of residents. The daily hours worked by care staff and the weekly shift arrangements must be reviewed with care staff. This is to ensure that care staff are not excessively tired and they are able to attend to the needs of residents. To ensure that the home complies with The Mental Capacity Act, the home should have a policy and procedure in place. This is to ensure that the welfare of residents is being protected and any deprivation of a resident`s liberty is lawful. CARE HOMES FOR OLDER PEOPLE Rosetrees Asher Loftus Way Colney Hatch Lane Friern Barnet London N11 3ND Lead Inspector Daniel Lim Key Unannounced Inspection 17th September 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosetrees DS0000010523.V366625.R02.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. Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosetrees Address Asher Loftus Way Colney Hatch Lane Friern Barnet London N11 3ND 020 8920 4150 020 8920 4171 aprior@jcare.org www.jewishcare.org Jewish Care 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) Manager post vacant Care Home 55 Category(ies) of Dementia - over 65 years of age (55), Old age, registration, with number not falling within any other category (55) of places Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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: Old age, not falling within any other category - Code OP Dementia over 65 years of age - Code DE(E) The maximum number of service users who can be accommodated is: 55 10th October 2007 2. Date of last inspection Brief Description of the Service: Rosetrees is a large purpose-built care home registered to provide personal care for a maximum of fifty-seven older people, some of whom may have dementia. The home was opened in 2001 and is run by Jewish Care. The stated aims of the home are to provide appropriate individual care for older members of the Jewish community who either choose or circumstances require them to live in residential care. The home is a large detached three-storey building with fifty-seven bedrooms. All bedrooms are for single occupancy and have en-suite facilities. There are two lifts serving all floors. There are communal toilets and assisted bathrooms on each of the three floors. The kitchen, office, reception and main lounge / diner are on the ground floor. Additional lounges and staff areas are located on the other two floors. There is a car park at the side of the building. The gardens are located at the front and side of the home and are accessible to residents. The home is located in a private road off Colney Hatch Lane which is close to local shops, public transport and other community services along Friern Barnet Road. The fees charged by the home range from £450 to £925 per week. Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 5 The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out on 17 September 2008 and took a total of eight and a half hours to complete. A second visit was made on the next day to view documents not examined and not available on the first day. We were assisted by the Assistant Manager of the home, Ms Angela Duran and the Assistant Director of Care Services, Jewish Care, Ms Gaby Wills. Six residents, two relatives and a community nurse were interviewed. The feedback received from them was positive and indicated that they were generally satisfied with the care provided. Completed survey forms were received from thirty-three residents, four staff and three healthcare professionals. These indicated that the respondents were generally satisfied with the care provided at the home. Statutory records were examined. These included six residents’ case records, the maintenance records, accident and incident records, financial records, complaints’ records and fire records of the home. The premises including residents’ bedrooms, communal bathrooms, laundry, kitchen (located in the adjoining Lady Sarah Cohen House), garden and communal areas were inspected. Five staff on duty and the hotel services manager were interviewed on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Staff records, including evidence of CRB disclosures, references, supervision and training records were examined. In addition, the minutes of residents’ and staff meetings were examined. These indicated that residents and staff had been consulted and informed of changes affecting the running of the home. The completed Annual Quality Assurance Assessment form (AQAA) was received by CSCI. Information provided in the assessment was used for this inspection. What the service does well: Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 7 The home is clean and furnished to a high standard. There are no offensive odours. Residents interviewed are happy with their accommodation and facilities provided. The meals provided are well balanced, varied and those interviewed said they are generally satisfied with these meals. The meals prepared are kosher and in accordance with the Jewish religious laws. The care provided is client centred and effort is being made to address the specific care needs and preferences of residents. Care documentation is comprehensive and care provided is regularly reviewed. The home has a varied and good range of activities which are appropriate for residents. This ensures that residents are provided with social and mental stimulation. A detailed record of activities engaged in is kept. Jewish holy days and festivals are celebrated at the home. Staff are caring and knowledgeable regarding their roles and responsibilities. There is an ongoing programme of training to ensure that staff are able to meet the needs of residents. Relatives and other visitors are made welcome at the home. They are given the opportunity to meet with the managers of the home at regular meetings and are invited to a number of formal social events held at the home. What has improved since the last inspection? A review of the personal care provided for the resident (identified to the manager during the inspection of 25/2/08) had been carried out to ensure that this person’s personal care needs are attended to. Staff had been instructed to treat all residents sensitively and with respect and dignity. Residents and relatives interviewed were able to confirm that they had been well treated. Arrangements were in place to ensure that staff undertake training in all areas identified in the last inspection report. Staffing levels of care staff on the dementia unit had been reviewed to ensure that there is sufficient staff available to care for the needs of residents. Two relatives interviewed were of the opinion that residents in this unit are well cared for and they spoke highly of staff on this unit. The manager had submitted an application for registration to CSCI to become the registered manager of the home. Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 8 The home had a management plan detailing which senior staff are responsible for the home in the absence of the manager and her deputy. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rosetrees DS0000010523.V366625.R02.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 Rosetrees DS0000010523.V366625.R02.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, 6 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken by the manager or a sufficiently skilled member of the organisation. This ensures that the home is able to meet the needs of residents. EVIDENCE: The pre-admission assessments which were examined were noted to be appropriate and comprehensive. They included details of the personal, mental, cultural and spiritual needs of residents. Risk assessments together with Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 11 strategies for minimising identified risks had also been prepared for residents admitted to the home. The home’s AQAA indicated that prospective residents “are offered the opportunity to visit the home and be shown around” prior to their admission and “the assessment process follows a standardised form to be completed to ensure that all significant areas are covered” and the home can meet the needs of prospective residents. Residents in the home were noted to be clean and appropriately dressed. The six residents who were interviewed informed us that they were well cared for and their care needs had been attended to. This was reiterated by two relatives who were interviewed and in completed questionnaires received by us. Comments made by residents and relatives included the following : “ They take good care of me ” “ Nice staff ” “Excellent care” and “ I am satisfied with the care provided.” The deputy manager stated that the home does not provide intermediate care. Rosetrees DS0000010523.V366625.R02.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, 10 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for meeting the healthcare and personal care needs of residents are on the whole satisfactory and these are recorded in residents’ care plans. Residents are protected by the home’s satisfactory arrangements for the administration of medication. EVIDENCE: The issue of health and personal care was discussed with residents. They indicated that staff took good care of them and had attended to their personal and healthcare needs. Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 13 When interviewed, they indicated that they could see a doctor if they needed to. The deputy manager indicated that the GP visits weekly and reviews the medication and treatment of residents. Case records which were examined, contained evidence that residents had access to other healthcare professionals such as the chiropodist, community nurse, GP and optician. Individual care plans had been prepared for residents. A sample of six care plans which was examined were found to be comprehensive and addressed the holistic needs of residents. This ensures that staff are provided with appropriate guidance and residents’ specific care needs are attended to. There was documented evidence of regular care reviews. Care plans had been signed by residents or their representatives. This ensures that they are aware of the care plans and agree with them. Appropriate risks assessments had been prepared for residents. These were generally of a good standard. The home’s AQAA stated that care plans identify a key worker for each resident and the team leader of the floor. This was noted to be evident in the care documents examined. In addition, the AQAA stated that dementia mapping had taken place in the home. The report was seen by the inspector. The deputy manager stated that recommendations made in this report had been responded to. The medication charts of four residents were examined. These indicated that medication had been administered as prescribed and signed for. The temperature records of the room where medication was stored had been recorded daily. These were satisfactory and no higher than 25 C. This ensures that medication is stored correctly. There is a record of medication disposed of. A visiting healthcare professional was interviewed in the home. She stated that the home maintained closed liaison with her and her instructions regarding the specific care of her client had been followed. The three completed questionnaires received from healthcare professionals indicated that the healthcare needs of residents had been attended to. The home’s AQAA indicated that the home is committed to an antidiscriminatory culture and residents are being cared for with respect and dignity regardless of their religion, race, disability, gender identity, sexual orientation or age. This was also confirmed by residents and relatives interviewed. They were of the opinion that they were not discriminated against and staff had an understanding of Jewish culture and their culture and beliefs were being respected. Rosetrees DS0000010523.V366625.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life, meal arrangements and routines of residents are well organised. The views of residents and their relatives are being sought when planning the home’s activities and routine. People using the service are given the opportunity to take part in a wide range of activities that are imaginative, appropriate and varied. They also have opportunity to maintain important family relationships. EVIDENCE: The home had a varied and comprehensive programme of weekly social and therapeutic activities. The deputy manager indicated that the programme of activities had been carefully planned to suit the preferences and needs of residents. Activities provided included Jewish religious services, quiz, exercise sessions, discussion groups, bingo, entertainment sessions, and arts and crafts sessions. The deputy manager stated that the home had a full time activities Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 15 organiser. In addition, care staff also assisted in one to one activities with residents. Residents’ case records included a social care plan together with details of activities that they had participated in. Jewish religious services and holidays were celebrated at the home. The home’s AQAA further added that a snoozlem unit has been used on the ground floor and first floor and this has “been very effective for some of our residents who have anxiety or dementia as it provides relaxation through sounds, smells and lights”. Residents interviewed were satisfied with the programme and of the opinion that the activities were appropriate. On the day of inspection, it was noted that residents were participating in a keep fit session during the morning and a dance session in the afternoon. A staff member was noted to be reading to a resident. One resident told the inspector that she especially enjoyed the dance session while another stated that she enjoyed the exercise session. A relative was pleased that staff had tried to encourage residents to join in the activities. The kitchen was clean and well equipped. The hotel services manager and chef were interviewed. They were knowledgeable regarding their responsibilities and the dietary preferences of residents. They stated that residents had been consulted regarding their meal preferences and there is always a choice of main dish. This was confirmed in the menu and by residents interviewed. The minutes of a residents’ meeting indicated that residents had been consulted regarding the meals provided and their concerns had been responded to. The menu examined was varied, balanced and reflected the Jewish cultural and religious preferences of residents. The dining area was well organised and spacious. Residents who returned their completed questionnaires and who were interviewed indicated that they were generally satisfied with the meals provided. The hotel services manager informed us that the kitchen had been inspected in October 2007 by the local environmental health officer and awarded 5 stars. The deputy manager informed us of an area of good practice in which residents could have their breakfast in bed if they wanted to and breakfast time was flexible and served over a period of two hours. Residents confirmed that they had been visited by friends and relatives. Two relatives who were interviewed said they had been well treated and staff were respectful towards them and residents concerned. Rosetrees DS0000010523.V366625.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection are satisfactory. The required policies and procedures for safeguarding residents were in place and give clear and specific guidance to staff. EVIDENCE: The six residents who were interviewed indicated that they were well treated and they knew who to complain to if they were dissatisfied with the care provided. The home had an adult protection procedure. It included information on examples of abuse and guidance to staff on reporting allegations of abuse to Social Services and The CSCI. The home also had a copy of the local authority adult protection guidelines. The deputy manager and her staff who were interviewed were aware of the home’s policy and procedures of the protection of vulnerable adults. There was evidence that they had been provided with the required training. Several complaints were recorded in the complaints book. There was evidence that these had been promptly responded to. The home had a record of compliments received. These indicated that relatives of residents thought Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 17 highly of staff and were grateful for the care provided by the home. Comments made by residents and their relatives included the following: “They do their best” “Staff are respectful and treat us well” “I can’t grumble, they look after me” However, two residents complained that on some occasions there appeared to be insufficient staff and the call bell was not answered promptly between 5 pm to 8 pm. This complaint was brought to the attention of the deputy manager who agreed to ensure that it was investigated in accordance with the home’s procedure. Rosetrees DS0000010523.V366625.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 26 People who use this service experience an excellent outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The living environment is appropriate for the particular lifestyle and needs of residents. It is homely, clean and furnished to a high standard. Residents are allowed to personalise their bedrooms. It has a wide range of up to date specialist equipment and adaptations. Overall, the home provides a pleasant and attractive environment to live in. EVIDENCE: The home is a modern building which has been well maintained. The required safety inspections had been carried out. All residents interviewed stated that they were happy with the accommodation provided and their bedrooms had Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 19 been kept clean. Bedrooms, lounges and other communal areas inspected were found to be clean and cheerfully furnished. No offensive odours were detected. All bedrooms have en-suite facilities. Bedrooms inspected had been personalised by residents with their own pictures and ornaments. These appeared comfortable and cosy. Call bells had been provided in all bedrooms and in communal bathrooms and toilets. A monitoring system was in place to ensure that call bells are answered promptly. Seating had been provided near the lift area on the ground floor. This enables residents to sit and have a chat with each other. The gardens around the home were attractive, colourful and seating had been provided. Comments made by residents included the following: “Spotless” “Very clean home” “Nice home” “My room is cleaned daily” The home’s AQAA stated that “a number of areas in the home had been redecorated” and “the first floor has had extensive refurbishment”. In addition, residents had been involved in choosing colour schemes for their bedrooms. The AQAA further stated that residents could use the synagogue located on the ground floor of the adjoining Lady Sarah Cohen House. Specialist equipment was available in the home. These included hoists, assisted baths, handrails in toilets, wheelchairs and pressure relieving mattresses. The laundry which was located on the ground floor of the adjoining Lady Sarah Cohen House, was inspected and arrangements for the laundering of soiled linen were found to be satisfactory. Laundry staff were noted to be knowledgeable regarding their responsibilities. Rosetrees DS0000010523.V366625.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The service has a good recruitment procedure that is followed in practice. The home recognizes the importance of training and tries to deliver a programme that meets statutory requirements. Residents and their representatives are on the whole, satisfied with the staffing arrangements. EVIDENCE: Two relatives interviewed were of the opinion that staff were competent and capable. Comments made by them included the following: “ Staff are excellent. They are respectful ” “My mother is well cared for. They do the best they can for her ” “Staff are excellent” Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 21 Five staff who were on duty were interviewed on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities and the care to be provided to residents. Staff interviewed stated that they had been instructed to treat all residents with respect and dignity regardless of their race, religion or sexual orientation. This was confirmed in the staff induction programme examined. The programme also included instruction on understanding Jewish culture. The deputy manager informed us that since the last inspection in February of this year, there is now an additional carer on each shift. The duty rota was examined. The rota indicated that in addition to the manager and her deputy and ancillary staff, there was normally at least 12 care staff during the day shift and 6 care staff on waking duty during the night shifts. There were 54 residents in the home during the inspection. Ancillary staff working at the home consisted of kitchen staff, cleaners and a maintenance person. Laundry staff are based in the laundry at Lady Sarah Cohen House. Most of those interviewed and who returned their completed questionnaires indicated that there was adequate staff in the home. However, two care staff and three residents indicated that sometimes there was insufficient staff available to support residents. Staff explained that this occurred when staff are on sick leave and not replaced. Two staff indicated that the shifts were too long and they get tired towards the end of their shift. One resident mentioned that there seemed to be a shortage of staff at weekends while two residents indicated that it was in the evenings. These concerns were discussed with the deputy manager who reassured the inspector that the staffing levels had been reviewed following the last inspection and staffing levels had been increased. She also informed the inspector that staff sickness is being closely monitored and interviews are carried out with staff who return from sick leave. She nevertheless, agreed to again review staffing levels and the deployment of staff. The training records examined, indicated that staff had been provided with the required training (such as health & safety, moving & handling, care of residents with dementia. fire training and adult protection). Recruitment records examined indicated that the required recruitment procedures (including obtaining of satisfactory CRB disclosures and two references) had been followed. This ensures that staff are recruited appropriately and residents are protected. Rosetrees DS0000010523.V366625.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. People living in the home can be assured that the home is well run and the manager has skills and ability to deliver a good quality of care. Residents and their representatives are consulted regarding the care provided and the management of the home. EVIDENCE: The home manager was on holidays during this inspection. However, both residents and staff indicated that the home was generally well managed and Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 23 they found the manager to be capable and approachable. The home’s AQAA stated that the manager’s aim is to create a home which is friendly, safe, warm and welcoming so that residents enjoy living there and staff enjoying working in it and the best interest of residents is at the forefront. There was evidence that staff and residents were consulted regarding the management of the home. Regular residents meetings had been held. This was confirmed by residents interviewed. The minutes of these meetings indicated that residents had been informed of progress within the home and concerns expressed by residents had been responded to. There was evidence that systems were in place to review the quality of care provided. A consumer survey had been carried out since the last key inspection of the home and the subsequent report published indicated that the satisfaction level was high and residents and their representatives were of the opinion that the home was well managed. Weekly health and safety checks had been carried out and these were documented. Weekly fire alarm tests, fire drills and fire training had been documented. The fire risk assessment had been updated and the fire authorities (LFEPA) who last inspected the home in August 2008 indicated in their report that the fire safety arrangements were satisfactory. Windows inspected had been fitted with window restrictors. These were engaged. The home had a current certificate of insurance. The financial records of four residents were examined. These were noted to be well maintained. Receipts had been obtained for transactions made on behalf of residents. The issue of complying with the Mental Capacity Act, 2005 was discussed. The Mental Capacity Act 2005 provides a statutory framework for people who lack the mental capacity to make their own decisions. It sets out who can take decisions, in which situations, and how they should go about this. It also enables people to make provision for a time in the future when they may lack capacity to make some decisions. The deputy manager and Assistant Director stated that the home does not have a policy and procedure in place. To ensure that the home complies with The Mental Capacity Act, the home should have a policy and procedure in place. This is to ensure that the welfare of residents is being protected and any deprivation of a resident’s liberty is lawful. Rosetrees DS0000010523.V366625.R02.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 X X 3 X x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X 4 X X 4 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 x 3 Rosetrees DS0000010523.V366625.R02.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 OP16 Regulation 22(3)(4) (5) Requirement The complaint that on some occasions there appeared to be insufficient staff and the call bell was not answered promptly between 5 pm to 8 pm must be investigated. This is to ensure that residents are promptly attended to. The results of the investigation must be forwarded to the CSCI. 2 OP31 10(1) 12(1) 18(1)(a) 01/11/08 The home must have appropriate contingency arrangements for ensuring adequate care staff cover when care staff are off sick. This is to ensure that there is adequate staff to attend to the needs of residents. 3 OP31 10(1) 12(1) 18(1)(a) 01/11/08 Staffing levels of care staff and the deployment of care staff on weekdays and at weekends must DS0000010523.V366625.R02.S.doc Version 5.2 Page 26 Timescale for action 21/10/08 Rosetrees be reviewed with staff and residents. This is to ensure that there is adequate staff to attend to the needs of residents. 4 OP31 10(1) 12(1) 18(1)(a) 01/11/08 The daily hours worked by care staff and the weekly shift arrangements must be reviewed with care staff. This is to ensure that care staff are not excessively tired and they are able to attend to the needs of residents. 5 OP37 12(1)(2) To ensure that the home complies with The Mental Capacity Act, the home must have a policy and procedure in place. This is to ensure that the welfare of residents is being protected and any deprivation of a resident’s liberty is lawful. 13/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP37 Good Practice Recommendations To ensure that the home complies with The Mental Capacity Act, the home should have a policy and procedure in place. This is to ensure that the welfare of residents is being Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 27 protected and any deprivation of a resident’s liberty is lawful. Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Rosetrees DS0000010523.V366625.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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