Care Home: Rosslyn

Similar services:

• Abbey The
• Snydale Care Home
• Hawkhills
• Larchfield Manor
• Beeches The - North Yorkshire County Council
• Carentan House
• Ravensworth Lodge

What the care home does well Rosslyn provides a comfortable and reasonable decorated place for people to live. Their needs are well assessed and a written plan is drawn up to make sure their personal care needs are met. All health care professionals` involvement and visits are recorded so the staff are aware of what professional advice has been given. Medication is safely handled. People are treated with regard to privacy and dignity. Visitors are made welcome. People have good Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 nutritious and varied food. One person said: `The food is good and we get plenty of it.` The home handles people`s money safely. What has improved since the last inspection? The home has a manager who has been in post for two weeks. She presents as determined and resourceful and has good plans for the improvement of care. The handling of medication has improved and is now managed safely. Safe working practice risk assessments have been produced but need development to make sure people are kept safe from harm. The provider has consulted with the fire authority and is making provision for the premises to be made safe from risk of fire. Staff have received induction training to make sure they have the training offer care based on best practice. What the care home could do better: The home has a number of shortfalls regarding the safety of the premises. The hot water in the bathroom was too hot and needs to be regulated to near 43 degrees. Window restrictors must be fitted to all opening upstairs windows to protect people from falling out, a risk assessment must be drawn up for access to an upstairs balcony. A number of safety and maintenance certificates were missing or out of date. People should have their social and recreational needs taken into consideration and staff have time allowed to assist people to spend their day the way they wish. The home needs to update the complaint procedure to include the correct address for CQC. Staff need up to date training in safeguarding adults. Staff should only be recruited after references have been taken out, only start working under supervision once a POVA first check has been done, only working independently once a Criminal Records Bureau check has been carried out. Staff need up to date foundation level training. The manager, Mrs Susan Griffin must be registered with CQC as soon as possible as the home has been without a registered manager for a longRosslynDS0000007728.V375335.R01.S.doc Version 5.2 period of time. This shortfall has contributed to the present poor rating. The provider must send regular regulation 26 visit reports each month to CQC to show he is monitoring the home and offering the support required to ensure the home has the best chance of improving its rating. The registered provider has not forwarded regulation 26 visits reports to CQC since January 2009. CSCI required him to provide such reports each month at the last key inspection in November 2008. The provider has not returned an Annual Quality Assurance Assessment to CQC, which is a legal requirement. He must do this within the stated time scale. The provider must work with CQC in a more transparent and responsive way, without CQC making requirements which are now being legally enforced. The provider should better support the manager in her new role and allow her the resources required to improve the level of care for people and their quality of life. Key inspection report CARE HOMES FOR OLDER PEOPLE Rosslyn 29 Bagdale Whitby North Yorkshire YO21 1QL Lead Inspector Karen Ritson Key Unannounced Inspection 7th May 2009 09:00 DS0000007728.V375335.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. Rosslyn DS0000007728.V375335.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 Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosslyn Address 29 Bagdale Whitby North Yorkshire YO21 1QL 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) 01947 820931 Mr Jeremy William Southgate Manager post vacant Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2008 Brief Description of the Service: Rosslyn provides long-term accommodation and personal care for a maximum of eleven older people. The home is located on a main route into Whitby and is conveniently situated for the shops and other community facilities including transport links. Rosslyn is a traditional house with modern extension built on two floors with the communal areas and two bedrooms being located on the ground floor. One bedroom has an en suite toilet facility. A stair lift gives access to the first floor for residents with limited mobility and consequently the residents placed in bedrooms on the first floor have to be reasonably ambulant. The home has its own parking facilities and there is on-road parking within close proximity. The front of the house has ramp access as well as steps. The home has a statement of purpose and service user guide, which provide information about the scope and nature of the care and facilities on offer. These, with CSCI reports, are available on request at the home. Hairdressing and newspapers are not included in the fee and these are charged at cost. Rosslyn DS0000007728.V375335.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 0 star. This means the people who use this service experience poor quality outcomes. The inspection for this service took twelve hours. This includes time spent gathering information, examining documentation before and after a site visit. It also includes the time taken to write the report. The site visit took place on 7th May 2009 between 9:30 and 15:00 with the lead inspector and an enforcement inspector. Information for this inspection was gathered from the following: 1. A visit to the home. 2. Speaking with people living at the home. 3. Speaking with staff. 4. Speaking with Adult and Community care staff. 5. Case tracking three people on the day of the site visit. 9. Examining policies, procedures and records kept at the home. 10. Examining information regarding the home on the file kept by CQC. All key standards were looked at during this inspection. The manager was available throughout the day of the site visit. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations -but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Rosslyn provides a comfortable and reasonable decorated place for people to live. Their needs are well assessed and a written plan is drawn up to make sure their personal care needs are met. All health care professionals’ involvement and visits are recorded so the staff are aware of what professional advice has been given. Medication is safely handled. People are treated with regard to privacy and dignity. Visitors are made welcome. People have good Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 6 nutritious and varied food. One person said: ‘The food is good and we get plenty of it.’ The home handles people’s money safely. What has improved since the last inspection? What they could do better: The home has a number of shortfalls regarding the safety of the premises. The hot water in the bathroom was too hot and needs to be regulated to near 43 degrees. Window restrictors must be fitted to all opening upstairs windows to protect people from falling out, a risk assessment must be drawn up for access to an upstairs balcony. A number of safety and maintenance certificates were missing or out of date. People should have their social and recreational needs taken into consideration and staff have time allowed to assist people to spend their day the way they wish. The home needs to update the complaint procedure to include the correct address for CQC. Staff need up to date training in safeguarding adults. Staff should only be recruited after references have been taken out, only start working under supervision once a POVA first check has been done, only working independently once a Criminal Records Bureau check has been carried out. Staff need up to date foundation level training. The manager, Mrs Susan Griffin must be registered with CQC as soon as possible as the home has been without a registered manager for a long Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 7 period of time. This shortfall has contributed to the present poor rating. The provider must send regular regulation 26 visit reports each month to CQC to show he is monitoring the home and offering the support required to ensure the home has the best chance of improving its rating. The registered provider has not forwarded regulation 26 visits reports to CQC since January 2009. CSCI required him to provide such reports each month at the last key inspection in November 2008. The provider has not returned an Annual Quality Assurance Assessment to CQC, which is a legal requirement. He must do this within the stated time scale. The provider must work with CQC in a more transparent and responsive way, without CQC making requirements which are now being legally enforced. The provider should better support the manager in her new role and allow her the resources required to improve the level of care for people and their quality of life. 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. Rosslyn DS0000007728.V375335.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 Rosslyn DS0000007728.V375335.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): 3 and 6. 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 care needs assessed so that the home knows if these can be met before agreeing to admission. EVIDENCE: People receive a comprehensive assessment of care needs prior to admission. No person has been admitted since the manager took up post. She plans to reassess each person and to develop new care plans based on these. Some of the people have a written life history, which allows staff to have the Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 10 information to chat with people about their families and what happened in the past. Most areas of care needs are considered, however, a consideration of people’s interests could be more detailed so that the home can plan how to offer activities that are personalised for each person. The home does not offer intermediate care. Rosslyn DS0000007728.V375335.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 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 personal care needs met, but their social and recreational needs are not fully met. EVIDENCE: A plan of care is available for each person and notes are made three times each day about how each person is and what they have been doing. These notes are adequate, though some entries need to be more detailed to give a clear picture of care needs and how these have been met. The previous Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 12 manager has drawn up most care plans and a care assistant copied the format when the registered individual made an admission last year. Health care professionals were consulted when drawing up the plan and all visits by such professionals are recorded on daily diary sheets. The home has separate sheets for recording health care professional visits but this has not been used since the previous manager left. The present manager has worked hard to familiarise herself with the care needs of each individual, and intends to review all care plans with the advice of each GP. Each care plan contains detailed notes on care required, including nutritional assessments, consideration of pressure areas, moving and handling risk assessments, and continence. Each care plan is also reviewed monthly, though little detail is given of any changes required, also there is no evidence that people or their representatives have been involved in the process. Although care plans cover all required areas of care, people’s interests could be better recorded. The home uses a Boots MDS system for medication, which means that most medication is received into the home in blister packs. Not all medication can be provided in this way however, and some packeted medication is used. The manager has a good auditing system in place to ensure that all medication is safely handled. However, there is no facility for storing controlled drugs. The manager must provide such a facility and the means to record the administration of controlled drugs. This is to ensure people have their medication administered safely should a controlled drug be prescribed. The manager should follow the guidelines set down by the royal pharmaceutical society for requirements about safe storage and recording of controlled drugs. None of the people living at the home are prescribed with controlled medication at present. Timodene cream, which should be stored in a cool place, was found on a window ledge in full sun. This should be kept according to direction. Staff who administer medication have all received training in the safe handling of medication. This ensures people are kept safe. Throughout the day of the site visit, staff were observed treating people with respect and regard to dignity. People said they were treated with kindness and enjoyed living at Rosslyn. One person said of a member of staff. ‘She’s our number one.’ Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 13 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. People are not enabled to make informed choice about the way they live their lives. Visitors are welcomed into the home and people receive a good diet they enjoy. EVIDENCE: The manager enables staff to have time to carry out activities with people each day. Such activities include dominoes, singing and watching films. Lunch times are a social occasion where staff sit with the people living at the home and chat. The manager plans to carry out assessments of people’s interests and hobbies so that staff know what individuals prefer to do. She also has plans to allow key workers to spend one to one time with each person, each week, Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 14 assisting them out to a café or for a ride in the car, or whatever they prefer to do. This would be good practice but has yet to commence. One person said she would like to go out more, and has to rely on her daughter to come and take her out if she is to go anywhere. The manager said she had difficulty gaining agreement from the provider to pay staff to spend time with people on activities and had so far been forced to use petty cash money to supplement staff wages. Staff must be paid through their normal wages for carrying out activities which are essential for wellbeing and quality of life. Economies in this area are not acceptable. The home will struggle to improve its rating if such economies continue and as a result, further placements at the home may be affected. Visitors are welcome at any reasonable hour. All are asked to sign in, are offered refreshments and asked if there are any comments they wish to make. This ensures the manager receives regular feedback about each person and can put any problems right quickly. Meals are home cooked, using fresh vegetables and local produce. Specialist diets can be catered for and a three weekly menu is in operation. People said the food was good. One person said: ‘It’s ok here, the food is good and we get plenty of it.’ Another person said: ‘The food is okay but my appetite is poor.’ This ensures people receive a varied and nutritious diet. Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 15 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are enabled to express their concerns and have these listened to and acted upon though the complaints policy requires updating. People are not sufficiently protected from risk of abuse. EVIDENCE: The manager encourages people to give her feedback about any concerns they may have regarding care. She is planning an open afternoon, where families and other visitors are invited to an informal social occasion, for her to introduce herself as the new manager and to encourage them to give feedback and comments on the care offered at the home. The home has a complaints procedure but this is out of date and has the incorrect address for people to contact CQC. This needs to be updated so that people have a clear pathway of complaint should they feel their concern is not adequately attended to by the manager. The manager has received abuse awareness and safeguarding training in the past but these needs to be updated as does the staff training in this area. The manager is aware of what she must do if she suspects abuse has taken place Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 16 and that social services is the lead authority in safeguarding adults. Updated training will ensure people are better protected. Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 17 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a reasonably redecorated home but the environment does not keep people safe from harm. EVIDENCE: The home is in need of redecoration and refurbishment to improve the quality of the environment. The lounge and other communal rooms are reasonable Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 18 decorated, and bedrooms are to be redecorated when time and funds allow. The hot water temperature in the bathroom was excessively high, registering at above 50 degrees. This causes a risk to people who could scald themselves. The cold -water tap in the sink would not turn on. The manager agreed to lock the bathroom door until the water temperature could be regulated to near 43 degrees and that all access to the bathroom would continue under supervision with staff. The proprietor was contacted regarding this. He said that the water was regulated at the tank. This clearly is not having the desired effect and people remain at risk. There were no records of regular hot water checks to see whether this is a regular problem. Hot water must be regularly checked and records kept to ensure people remain safe from scalding. The door to room 5 leads out onto a balcony, on the day of inspection the key was in the lock and people would have easy access to the room. The balcony overlooks the car park and no risk assessment is in place for this. A risk assessment must be devised immediately as this poses is a risk to safety. One door was wedged open; this produces a fire hazard and the wedge must not be used. There were no window restrictors on some of the upstairs windows. Window restrictors must be fitted to prevent people from being at risk of falling from upstairs windows. There was some damp damage to wallpaper in room 3, which should be remedied. The home had consulted with the fire authority and has recently carried out work to ensure people are safe from risk of fire. The fire authority has yet to confirm that this is to a standard to protect people from risk of fire. The home needs to carry out regular fire alarm testing so that people are aware of what they need to do in the event of a fire. Staff said they had covered fire safety in their induction training. The provider was required to send CQC regulation 26 reports following the last inspection. He sent a regulation 26 report for January, but CQC received nothing for February, March or April. The provider was contacted and questioned about this during the inspection. He agreed to send the reports by fax within the hour. Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 19 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is adequately staffed to meet the personal care needs of people, but requires extra staff hours at peak times to enable people to have their social and recreational needs met. Staff are not adequately trained or recruited to offer the correct, safe care to people. EVIDENCE: Two members of staff are on duty each shift this includes the manager. At night there is one waking and one sleeping member of staff on duty. On the day of inspection there were only five people at the home, a sixth was in hospital. This staffing level is adequate for this number of people. However, if the numbers were to increase this would have to be reviewed. The staff on duty complete all required tasks in the home including making meals, laundry and cleaning. This does not allow for staff to have time to take people out or to engage in activities. Extra staff hours must be available at peak times to meet people’s social and leisure needs. Most staff are on a course of study, which Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 20 will lead to NVQ at level 2, however, at the moment not quite 50 have this qualification. The manager is working towards NVQ at level 3, and will then go on to obtain level 4, which is required for her role. Most staff are well recruited, with references and CRB checks in place. One member of staff on duty on the day of inspection did not have references on file and there was no evidence of a CRB check but a POVA first check had been carried out. This means the member of staff could work at the home under supervision, however, she was clearly carrying out duties independently. All staff must have evidence of CRB checks before they can work unsupervised. The home has a history of not having gaining CRB checks for staff in a timely way. Staff have completed skills for care induction. The manager is planning to update foundation training, which is out of date for some staff. Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 21 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 and 38 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a determined and resourceful newly appointed manager, but the home has not been well managed since the last inspection. People’s views are not yet taken on board when planning improvements to the service and there is no quality assurance system. People have their money safely looked after. The home does not operate sufficiently safe working practices to ensure people are protected from risk of harm. EVIDENCE: Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 22 The manager has only been in post for two weeks. During this time she has begun to familiarise herself with the residents and their needs, has met with staff and has spent time on required paperwork and recording. She has not managed a care home before but has experience of working in care homes in the past. The provider had not made her aware of the National Minimum Standards and Regulations, which is the framework used by CQC to regulate care services. In the absence of a manager for the home, the provider has not returned the Annual Quality Assurance Assessment to CQC, which is a legal requirement. Discussion took place on the day of inspection about this and about where the manager could get more information to assist her in the role of manager. The provider should have given this information to his manager on appointment to allow her to understand the legal requirements of her role. She has no time allotted for management duties in her day and was permitted only two days supernumerary experience when she began working at the home. A longer period would have allowed her to observe the staff and to begin to understand her role better. She presented as capable and determined to provide the best level of care possible with the resources at her disposal. She has already worked well with staff to help them to understand the requirements of good care and to improve running the home for the benefit of the people living there. The member of staff on duty said that staff now referred to her on matters of concern and said she found the manager very approachable and supportive. She said: ‘The new manager is good. I feel she will sort things out.’ She stated she had already been offered training in dementia care, manual handling and health and safety and was signing up for NVQ 2 the next day. The manager has not yet had the chance to implement a quality assurance system. The home keeps some personal allowances for people. These are kept safely and accurately and are well recorded. The inspectors saw lift servicing certificates which were up to date, a gas safety certificate was a year out of date and there was no up to date electrical wiring certificate. The last certificate the manager could find for electrical safety was dated 1995. An up to date electrical safety certificate must be forward to CQC. Environmental shortfalls have been covered in the environment section of this report. Environmental risk assessments were adequate, but required updating and developing to ensure people were kept safe. The manager is looking into a more hygienic method for the disposal of clinical waste. Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 07/05/09 1 OP38 13 (4) (a) 2 OP38 13 (4)(a) 3 OP38 13(4)(a) 4 OP38 13(4)(a) 5 OP19 23(2)(b) The registered person must ensure that hot water is regulated in the bathroom and all hot water supplies which service users have access to provide a temperature at close to 43 degrees. While water temperatures remain high, a risk assessment must be put in place to ensure service users remain protected from risk of scalding. All opening upstairs windows must all be fitted with restrictors, to prevent the risk of service users falling from open windows. All maintenance and safety certificates must be brought up to date, including the gas safety and electrical safety certificates. Copies of these certificates to be forwarded to CQC by the given date. The fire alarm must be tested at such a frequency to protect service users from risk of harm from faulty fire detection. The areas of water damage to the wallpaper must be remedied to ensure service users enjoy a home, which is in a good state of repair. 31/05/09 30/06/09 07/05/09 30/06/09 Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 26 6 OP12 12(2)(3) Service users must have their 31/07/09 interests more fully assessed and be given opportunities to choose interesting and stimulating activities and enabled to follow them. Individual interests must be written into care plans. The registered person must ensure that the manager and all staff have updated abuse awareness training to protect service users from harm 31/07/09 7 OP18 13(6) 8 OP30 18(1)(a)(c The registered provider must ) ensure that staff receive foundation training to enable them to offer care based on best practice. 18(1) (a) Staffing must be at such a level to ensure service users are enabled to have their social and recreational needs met. 31/08/09 9 OP18 31/05/09 10 OP38 13(4)(a) 11 OP38 23(4)(a) 12 OP29 19(1)(b) The manager must draw up a 07/05/09 risk assessment regarding access to the balcony in the upstairs room 5. The use of door wedges in fire 07/05/09 doors must cease to prevent the risk of fire spreading throughout the building. All staff must have two 31/05/09 references and current CRB checks in place to protect service users from people unsuitable to work with vulnerable adults. Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7 Refer to Standard OP36 OP38 OP7 OP38 OP33 OP22 OP31 Good Practice Recommendations Staff should receive regular supervision in line with standard 36. The provider must continue to provide written regulation 26 reports to CQC each month. Evidence should be available that service users and advocates are involved in care plan reviews. The manager should make provision for the suitable disposal of clinical waste. The manager should implement a quality assurance system to ensure practice is based on auditing and upon the views of those using the service. The complaints procedure must be updated to include contact details of the CQC. The manager must enrol on a course of study leading to NVQ level 4 in care and a management qualification to show she has the qualifications necessary to manage the care home. Rosslyn DS0000007728.V375335.R01.S.doc Version 5.2 Page 28 Care Quality Commission Yorkshire & Humberside Region PO Box 1254 Newcastle upon Tyne NE99 5AR 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. Rosslyn DS0000007728.V375335.R01.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!