Care Home: Rowan House

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What the care home does well Rowan House is homely, comfortable, and well decorated and maintained. The large kitchen/dining room is the focal point of the home. The people who live there, staff, and visitors, sit and chat here as food is prepared, and people come and go to and from various activities. The atmosphere is warm and friendly and there is always someone to talk to and something happening to keep everyone interested and involved in life at the home. All the people who live there wanted to be involved in this inspection. The impression given was that Rowan House is their home, and anything concerning it concerns them. They were all positive about the home. One said `I like it so much at Rowan House that my feet are cemented here.` Another told us, `There`s not a fault with this home.` We also received good feedback about the home from the relatives and staff who completed surveys prior to the inspection. One relative wrote, `Rowan House supports people to live the life they choose and evokes a sense of belonging.` And a member of staff told us, `Rowan House provides a safe, caring environment.` All the people who live in the home have their own programme of recreational, educational, and vocational activities. In discussions they talked to us about the sort of things they like to do. Comments included, `I help in the garden, go swimming, and go to the shops and the day centre`, `At college I`ve finished a skills course`, and, `I make my bed and do the cooking and I wash up and dry up and I clean my room`. Mealtimes in the home are a relaxed affair. Care staff prepare the food, sometimes helped by the people who live in the home. They are no set menus. Instead meals are decided on the day when staff ask everybody what they would like to eat. The people who live in the home told us this flexible approach suits them. One told us, `I ask for what I want at dinner and providing we`ve got it, I get it.` Rowan House is run by an experienced and qualified Manager who is `hands on`, and actively involved in everything that happens at the home, both during the week and at weekends. She knows all the people who live in the home well and they made many positive comments about her including, `Anne is marvellous. She has been helping me to be independent, she puts things right`, and `I`m happy with Anne and Roy (the Owners) and their dog.` What has improved since the last inspection? Medication policies and procedures have been reviewed to ensure medication is safely managed and administered. The front lounge and some bedrooms have been redecorated, a summerhouse has been erected in the garden for use as an office, some bedrooms have had new floor coverings, and a new boiler has been installed. What the care home could do better: Admission forms need updating so all the information staff need is readily accessible when a new person moves into the home. A quality assurance system should be put in place. This wil help the Manager and staff ensure they provide the best possible care for the people who live in the home. Access from the conservatory lounge into the garden needs improving so it is more accessible to people with limited mobility. CARE HOME ADULTS 18-65 Rowan House 2 Spa Lane Hinckley Leicestershire LE10 1JB Lead Inspector Kim Cowley Unannounced Inspection 2nd July 2008 11:45 Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowan House Address 2 Spa Lane Hinckley Leicestershire LE10 1JB 01455 613749 01455 633009 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Ann O`Neill Mr Roy William McCormick Mrs Ann O`Neill Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 30th August 2006 Brief Description of the Service: Rowan House is a large Victorian property that accommodates up to eight people with learning disabilities. The home is situated close to the centre of Hinckley with shops and bus routes. Accommodation is on two floors with stairs for access. All bedrooms have their own ensuite toilets and some have showers. Downstairs are two lounges and a kitchen/dining room. At the back of the home is a secluded garden with a patio area Further information about the home is available from the Registered Manager. The fee levels are at current local authority rates. There are additional costs for personal items and some recreational activities Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was a key inspection that included a visit to the home and inspection planning. Prior to the visit, we (throughout the report the use of ‘we’ indicates the Commission for Social Care Inspection) spent half a day reviewing information relating to the home. During the course of the inspection, which lasted six hours, we checked the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means we looked at the care provided to three of the people living at the home by meeting them; talking with the staff who support their care; checking records relating to their health and welfare; and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home, including health and safety and management issues, were examined. We also talked to five other residents, the Registered Manager, and three carers. Two relatives surveys, and two staff surveys were returned to CSCI prior to this inspection. All respondents made positive comments about the home. What the service does well: Rowan House is homely, comfortable, and well decorated and maintained. The large kitchen/dining room is the focal point of the home. The people who live there, staff, and visitors, sit and chat here as food is prepared, and people come and go to and from various activities. The atmosphere is warm and friendly and there is always someone to talk to and something happening to keep everyone interested and involved in life at the home. All the people who live there wanted to be involved in this inspection. The impression given was that Rowan House is their home, and anything concerning it concerns them. They were all positive about the home. One said ‘I like it so much at Rowan House that my feet are cemented here.’ Another told us, ‘There’s not a fault with this home.’ We also received good feedback about the home from the relatives and staff who completed surveys prior to the inspection. One relative wrote, ‘Rowan House supports people to live the life they choose and evokes a sense of Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 6 belonging.’ And a member of staff told us, ‘Rowan House provides a safe, caring environment.’ All the people who live in the home have their own programme of recreational, educational, and vocational activities. In discussions they talked to us about the sort of things they like to do. Comments included, ‘I help in the garden, go swimming, and go to the shops and the day centre’, ‘At college I’ve finished a skills course’, and, ‘I make my bed and do the cooking and I wash up and dry up and I clean my room’. Mealtimes in the home are a relaxed affair. Care staff prepare the food, sometimes helped by the people who live in the home. They are no set menus. Instead meals are decided on the day when staff ask everybody what they would like to eat. The people who live in the home told us this flexible approach suits them. One told us, ‘I ask for what I want at dinner and providing we’ve got it, I get it.’ Rowan House is run by an experienced and qualified Manager who is ‘hands on’, and actively involved in everything that happens at the home, both during the week and at weekends. She knows all the people who live in the home well and they made many positive comments about her including, ‘Anne is marvellous. She has been helping me to be independent, she puts things right’, and ‘I’m happy with Anne and Roy (the Owners) and their dog.’ What has improved since the last inspection? What they could do better: Admission forms need updating so all the information staff need is readily accessible when a new person moves into the home. A quality assurance system should be put in place. This wil help the Manager and staff ensure they provide the best possible care for the people who live in the home. Access from the conservatory lounge into the garden needs improving so it is more accessible to people with limited mobility. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who want to come to the home have their needs assessed to ensure it is suitable for them. This judgement has been made using available evidence including a visit to this service. Standard 2 was inspected. EVIDENCE: The people who live in the home told us about their experiences of visiting the Rowan House prior to admission: ‘I came and looked at the room and I thought it was brilliant and I still think it’s brilliant.’ ‘When I first came here everybody was so nice to me’ ‘I came here from another care home. I really fancied living here when I saw it for the first time so I came here.’ People who want to live at Rowan House first have a written assessment to see if the home is suitable for them. The Manager completes this, taking into account their views, and the views of their families and friends. Health and social care staff who are involved in their care are also consulted. This helps to ensure that the home will be able to meet their needs if they decide to move in. They are then invited to visit the home as many times as they like, staying overnight if they wish, until they are ready to move in. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 10 The people who are already resident in the home are consulted before a new person moves in. The Manager told us, ‘They’ve got to live with the person so it’s more their decision than ours. We wouldn’t go against their wishes if they had a valid reason for not wanting a particular person to move in.’ We inspected admission forms belonging to the people who live in the home that we case tracked. We found that not all the required information was in place, although it could be found in other parts of their case files. Admission forms should be should be redesigned so they include all the information required in Schedule 3 of Care Home Regulations 2001. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. The people who live in the home are involved in writing their own care plans and are encouraged to take responsible risks and make choices about all aspects of their lives. This judgement has been made using available evidence including a visit to this service. Standards 6, 7, and 9 were inspected. EVIDENCE: All the people who live in the home have care plans that cover their health, personal and social needs, likes/dislikes, and preferred lifestyles. They are involved in deciding what goes in their care plans, and sign to say they are in agreement with them. The Manager told us that she often discusses care plans with the people who live in the home at weekends. She said, ‘I often sit in the lounge and chat to them informally about what they want to achieve. I get better results this way as they are more relaxed and can open up to me.’ Those who live at Rowan House are encouraged to make choices about all aspects of their lives. One of them told us, ‘I tell myself what to do here. I tell myself what to do all the time. I choose what I do.’ Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 12 Some of the people who live in the home are moving towards independent living and this is reflected in their care plans. This will help to ensure that everyone involved in their care knows what their goals are and can help them achieve them. They are also helped to take responsible risks, for example using public transport on their own. Staff only intervene if there are serious concerns about their well being. This will help them to increase their independence and decision making skills, while at the same time remaining safe. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Daily living and social activities enable residents to lead full lives and grow in independence. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 15, 16, and 17 were inspected. EVIDENCE: All the people who live in the home have their own programme of recreational, educational, and vocational activities, depending on their needs and what they want to achieve. In discussions the people who live in the home talked to us about the sort of things they like to do, and how staff help them get out into the community. Comments included: ‘I help in the garden, go swimming, and go to the shops and the day centre.’ ‘At college I’ve finished a skills course’ ‘I do cooking at college.’ ‘I like looking after the chickens we keep in the garden.’ ‘I watch the TV, I chill out, I relax, I watch my DVDs, ‘I make my bed and do the cooking and I wash up and dry up and I clean my room’. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 14 Records showed that staff help the people who live in the home to discover what interests them and what their goals are. These are identified in care plans so staff can help them achieve their ambitions, for example, living independently, using public transport, or having a holiday abroad. Some activities are shared with the people who live in Rowan House’s sister home, the Briars, which is a few minutes walk away. The two homes also share a minibus and people carrier. Staff support the people who live in the home with their friendships and relationships, providing guidance and support where necessary. Mealtimes in the home are a relaxed affair. Care staff prepare the food, sometimes helped by the people who live in the home. They are no set menus. Instead meals are decided on the day when staff ask everybody what they would like to eat. The people who live in the home told us this flexible approach suits them. One told us, ‘I ask for what I want at dinner and providing we’ve got it, I get it.’ Menu records showed that the food is varied and wholesome and there is always an alternative if the people who live in the home want one. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The people who live in the home have their personal and health care needs met in the way they want by staff in the home. This judgement has been made using available evidence including a visit to this service. Standards 18, 19 and 20 were inspected. EVIDENCE: The people who live in the home are encouraged to be as independent as possible and are supported to care for themselves. Where necessary, support and guidance is offered in a sensitive and flexible manner. Care plans provide the information staff need to provide appropriate help and support and alert them to individual’s likes and dislikes. Records showed they use local health care services, for example GPs, opticians and dentists. All have ‘Health Action Plans’ in place which help staff to ensure their health care needs are met. Where possible the people who live in the home are expected to become responsible for their own medication. Records showed that when they do this they are well-supported by staff. Other residents have their medication administered by staff with a view to becoming more independent in the future. Since the last inspection medication policies and procedures have been reviewed to ensure medication is safely managed and administered. The Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 16 Manager told us that further staff training in medication administration is being planned to ensure staff are up to date with what is required of them. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Staff know how to safeguard the people who live in the home and help them express any concerns they might have. This judgement has been made using available evidence including a visit to this service. Standards 22 and 23 were inspected. EVIDENCE: We spoke to every person living in the home and they all said they knew what to do if they had a complaint or weren’t happy about something. Comments included: ‘If I was upset I’d tell Anne. She is here every day.’ ‘I’d tell Anne if I was unhappy’ ‘If not happy I’d tell Anne or a member of staff.’ A relative told us that they knew how to make a complaint, if necessary, and that the Manager and staff always responds appropriately if concerns are raised. One complaint about the home has been received since this last inspection. This was investigated by social services and satisfactorily concluded. Staff at the home co-operated fully with the investigation. They responded to the findings by putting an action plan in place to improve the area of the service in question. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home is community-based, comfortable, and well maintained. This judgement has been made using available evidence including a visit to this service. Standards 24 and 30 were inspected. EVIDENCE: The premises are homely and comfortable. The large kitchen/dining room is focal point of Rowan House. The people who live there, staff, and visitors, sit and chat here as food is prepared, and people come and go to and from various activities. The atmosphere is warm and friendly and there is always someone to talk to and something happening to keep everyone interested and involved in life at the home. A person who used to live in the home, but now works there cleaning and cooking, showed the inspector round. All the bedrooms are unique to the person who lives in them, well decorated, and full of personal items belonging to their occupants. Some have separate living and sleeping areas and ensuite showers, all have ensuite toilets. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 19 Downstairs there is a conservatory lounge that overloooks the garden. The Manager said this is popluar with the residnets and quite busy at times. At the other end of the home is a second lounge which is quieter and more peaceful. Since the last inspection the following improvements have been made to the home: • • • • the front lounge and some bedrooms have been redecorated a summerhouse has been erected in the garden for use as an office some bedrooms have had new floor coverings a new boiler has been installed The garden is secluded and well maintained. There is a patio with seats, and a lawn behind it. The people who live at the home keep chickens in a pen in a garden. The home’s office is situated in a summer house in the garden. Access to the garden in one area needs improving (see ‘Conduct and Management of Home’). In the grounds an old stable block is being converted into an activity and teaching centre which the people who live in the home will be able to use. This is to be called the Annex, and the Manager told us a local college will be running courses there three days a week. On other days it will be used by Team Enterprise (a small business run by the people who live at Rowan House and the Briars), and for other educational and leisure activities. All the areas we inspected were cleaned to a high standard and well maintained. The majority of the cleaning is carried out by the care staff, helped by the residents. The Manager told us, ‘We have a flexible approach to cleaning. We encourage residents to help out, but we don’t have a rota. After all we don’t go home and look at a rota to see if our bedroom needs cleaning, so why should they!’ Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The people who live in the home have their needs met by friendly and professional staff. This judgement has been made using available evidence including a visit to the service. Standards 32, 34 and 35 were inspected. EVIDENCE: The staff on duty during the inspection were friendly and helpful. We saw they got on well with the people who live in the home. They were observed working closely with them, helping them to make choices, and accompanying them out into the community. The relationship between the people who live in the home and the staff was informal and warm, with lots of shared jokes and banter. The people who live in the home told us they liked most of the staff. One said, ‘The staff are my friends’, and another commented, ‘The staff are nice and kind.’ Two said they weren’t keen on one member of staff who they said was ‘sharp’. This was discussed with the Manager who said she was aware of this problem and was addressing it. Recruitment procedures were discussed with the Acting Manager. She told us that all staff are subject to CRB and POVA checks, and references are obtained. Staff files were sampled and had the appropriate documentation in place. This helps to ensure residents are safeguarded. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 21 Staff receive good training opportunities and there is programme of appraisal and supervision in place. This will help to ensure staff have the support and skills they need to carry out their work. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home is safe and well managed and the people who live there are actively involved in the way it is run. This judgement has been made using available evidence including a visit to this service. Standards 37, 38, 39, 42 and 43 were inspected. EVIDENCE: Rowan House is run by an experienced and qualified Manager who is ‘hands on’, and actively involved in everything that happens at the home, both during the week and at weekends. She knows all the people who live in the home well and they made many positive comments about her including: ‘Anne is marvellous. She has been helping me to be independent, she puts things right.’ ‘I’m happy with Anne and Roy (the Owners) and their dog.’ ‘I love Anne – you can’t fault her, she’s like the mum I never had. She’s been a miracle to me – she’s my guardian angel.’ Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 23 Consultations with the people who live at the home are central to how it is run. Every day the Manager and staff chat to them informally, either in groups or on a one-to-one basis, to gather their views and encourage them to play an active part in choosing the day’s meals and activities. More formal group meetings are also held every three to four months with minutes taken. This helps to create an empowering environment, which will help the people who live in the home to grow in independence and confidence. At present the home does not have a formal quality assurance system, although quality is monitored informally in some key areas. One should be put in place so the Manager and staff can ensure they provide the best possible care for the people who live there. (For further information about what is required please see Regulation 24 of the Care Homes Regulations 2001.) During the inspection we saw that some of the people who live in the home had difficulty getting up and down the step from the conservatory lounge into the garden. We saw that staff assisted them where necessary to reduce risk, but it would be better if they could access the garden independently from this exit. It is recommended that improvements are made, for example by fitting a grab rail and/or a ramp, to improve access to the garden for people with limited mobility. Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X 2 X 2 Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA2 Good Practice Recommendations 1 Admission forms should be redesigned so they include all the information required in Schedule 3 of Care Home Regulations 2001. Improvements should be made to the access from the conservatory lounge to the garden. Fitting a grab rail and/or a ramp would make it easier for people with limited mobility to use this exit. A formal quality assurance system should be put in place so the Manager and staff can ensure it provides the best possible care for the people who live there. (For further information about what is required see Regulation 24 of the Care Homes Regulations 2001.) 2 YA42 3 YA43 Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Regional Office CPC1 Capital Business Park Fulbourn Cambridge CB21 5XE 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 Rowan House DS0000057197.V367644.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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