Care Home: Rowles House Limited

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What has improved since the last inspection? This is the first inspection undertaken since the registration of Rowles House on 28 January 2009. Therefore, no improvements could be noted. What the care home could do better: There are 2 requirements and 1 recommendation arising from this report, which need to be addressed. Bedrooms with chipped paint and some of the bathroom/shower and toilet facilities require upgrading. This would ensure that residents have a comfortable environment. Moving & Handling and First Aid must be completed by staff that has not done this mandatory training. This would ensure the safety of residents and staff. Recommendation The care and support given to each resident should be recorded on each shift; this would provide a comprehensive audit trail of how identified needs are being met. Key inspection report CARE HOMES FOR OLDER PEOPLE Rowles House Limited 28-30 Barton Road Luton Bedfordshire LU3 2BB Lead Inspector Neil Fernando Key Unannounced Inspection 1st July 2009 10:20 DS0000073249.V376185.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. Rowles House Limited DS0000073249.V376185.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 Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowles House Limited Address 28-30 Barton Road Luton Bedfordshire LU3 2BB 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) 01582505692 01582572824 Rowles House Limited Donna June Marie Pitty Care Home 26 Category(ies) of Dementia (26), Mental disorder, excluding registration, with number learning disability or dementia (26), Old age, of places not falling within any other category (26), Physical disability (26) Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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 - Code DE Mental Disorder, excluding learning disability or dementia - Code MD Physical Disability - Code PD The maximum number of service users who can be accommodated is 26 This is a new service 2. Date of last inspection Brief Description of the Service: Rowles House is registered to accommodate up to 26 older people who may also have dementia and or mental disorder or physical disability. The home is situated in a residential area of the north side of Luton, on the main A6 road. Rowles House is a conversion of two large houses and offers twenty-two single and two shared rooms. There are four lounge/dining areas with a conservatory, all on the ground floor. There are ample toilet/shower facilities. There is a passenger lift to the first floor and adequate kitchen and laundry facilities. There is a very attractive and large enclosed garden and recreation space to the rear of the property, which is accessible to residents. Ample off-road parking is available to the front of the property. The home has its own transport, which is helpful to access various activities in the community. A copy of the service user’s guide and an information pack is available for residents and visitors to read. The fees for this service vary between £460 and £540, per resident per week; the exact fees are reflected in individual service contracts for the residents. Rowles House Limited DS0000073249.V376185.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. We, the Care Quality Commission, undertook the first unannounced key inspection of this home on 1 July 2009. Rowles House Limited is the registered provider since 28 January 2009 We spoke with 5 residents, 3 visiting relatives, the manager and deputy manager, and 4 staff members including 1 activities coordinator and the cook. We spent some time observing residents and staff care practices so we could assess how staff interacted with and assisted with the care and support of residents. We undertook a brief tour of the home and viewed some of the records the home must keep. At the time of the visit, there were 24 people in residence, with 2 vacancies. We have received the AQAA (Annual Quality Assurance Assessment - a document, which gives the manager the opportunity to tell us how well outcomes are being met for people living in the home); it provides good details about the service. We have also received surveys from 5 residents and 3 staff. The manager was available throughout the inspection and the director of care, for some of the time. What the service does well: The inspection indicates that the home is being well managed. Residents expressed a good deal of satisfaction in respect of the quality of service they receive. Their views including those of staff and visiting relatives have been reflected throughout the report. The assessment and admission processes for new residents are good, thus ensuring that their identified needs could be met on admission. The health and personal care needs are clearly woven in the care plan for each resident; these are being monitored internally through a monthly review system. The level and variety of social and recreational activities facilitated is exceptionally good. This means that residents benefit from a high level of stimulation, which promotes their welfare and general well being. Comments from residents include There is always something going on that I enjoy’; ‘I have plenty to do all day, everyday and interesting as well’. Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 6 Equality and diversity issues are being well promoted. Residents are being proactively encouraged to live the lifestyle they prefer and practice their culture and religion, as they wish. Families are proactively involved in the decision-making process in the lives of their relatives accommodated at this home. The accommodation is homely and comfortable. A high standard of cleanliness was evident throughout those areas viewed. Staffs work well as a team and they are very positive about their work. NVQ training is being given a high profile, which means that staffs are being equipped with appropriate skills and knowledge to provide an improved quality of service. Care and staff management systems, including health and safety are being implemented to good effect. The manager is very supportive of the staff team. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 7 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. Rowles House Limited DS0000073249.V376185.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 Rowles House Limited DS0000073249.V376185.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): Standards 2, 3, 4 and 5. Standard 6 is not applicable. People using the service experience good quality outcomes in this area. All new residents have their needs fully assessed and they are able to visit the home, prior to admittance. In this way, both the resident and staff can be sure that the home can meet their identified needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A copy of the written contract of occupancy/statement of terms and conditions is available in each of the three case files viewed; it also includes the signature of the resident, their representative and the home manager, as appropriate. Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 10 ‘The placement contract is being updated in a more user friendly format’, reported the manager. The care records for three residents were assessed and evidence indicates that the manager undertakes a satisfactory pre-admission assessment of needs before any new person can be admitted to the home. The assessments include information from placing authorities and health care providers where people are admitted from hospital. Information from residents, the manager and staff members, and records provide evidence that the arrangements to enable residents and their representatives the opportunity to visit and make an informed decision about the facilities offered at Rowles House is satisfactory. ‘My son had visited and chose this place for me as I was at the hospital at the time’, said a resident. The resident is admitted on a trial basis to enable them decide if they want to stay at the home. A review meeting is held at the end of the trial period involving the resident, their representative and the placing authority; only then the placement is made permanent. Good evidence is available to demonstrate that residents are being empowered to participate in the decision making process, on issues that matter to them. Rowles House Limited DS0000073249.V376185.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): Standards 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. The residents observed during the course of the visit appeared to be well cared for and they were being treated with dignity and respect. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA tells us ‘Set up detailed individual care plans, identifying all needs and choices for, health, personal and social wellbeing and a plan for how these may be achieved. Ensuring that they are monitored and reviewed regularly (or monthly as a munimum requirement), with the resident/family where possible and recorded correctly’. Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 12 The care plan is developed with contribution from the resident, their representative and home staff. Information from care plans, residents and staff members indicates that the needs of residents are being identified and addressed satisfactorily. The care plan indicates how the identified needs are to be met. The care given, progress made and interactions with other residents are recorded. However, this should occur on each shift, in order to provide a comprehensive audit trail of relevant development for each resident, on each shift. Residents’ records viewed evidence that their health care requirements are being appropriately addressed. The resident and their representative, where appropriate, have also signed the care plan, thus demonstrating their participation in the care planning process. Some of the residents spoken with identified their key worker by name and they provided good examples of how their key worker assists them on a daily basis. Staff spoken with also reported that the key worker system is very helpful; ‘The key worker ensures that the needs of their key resident are implemented’, said a staff. Care plans are reviewed monthly to reflect the changing needs and objectives for health and personal care. Review minutes are being maintained and they also reflect the signature of the resident where appropriate. Risk assessments are completed for each resident and these are reviewed as and when required. All staff authorised to administer medicines have received training. Records including receipts and storage, administration, and disposal of medicines are in good order. All residents are registered and have access to a GP. All residents spoken with expressed a high level of satisfaction in the manner their health care needs are being addressed. ‘I see my doctor when I need to’, said a resident. Residents also have access to district nurse, dentist, optician, podiatrist, and dietician. Staff members on duty were seen to deliver care and attend to residents’ needs in an extremely sensitive manner that very much respects their privacy, dignity, choice and wishes whilst actively promoting their independence. ‘Staff pursue their duties with utmost care and they are definitely courteous and very welcoming’, said a visiting relative. There is also very good evidence to demonstrate that personal and intimate care practices are carried out behind closed doors. Rowles House Limited DS0000073249.V376185.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): Standards 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. The social, cultural, religious and recreational interests of residents are being well addressed. The quality and variety of food offered is of a good standard. This means that residents’ welfare is being well promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA states ‘We gather as much background information on each individual to identify their previous lifestyle, in order to establish their expectations, preferences and accommodate their social, cultural, religious and recreational interests and needs’. There are 2 activities coordinators available and they provide a total of 36 Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 14 hours input weekly. Evidence indicates they facilitate a wide range of activities to suit residents needs. Activities are arranged either individually or in small groups; they are both planned and ad-hoc, to make the most of the weather for example, or the expressed wishes of the residents. On the day of the inspection, the activities being facilitated included ‘sing-a-long, quiz and ice cream social’. We observed that at least 16 residents actively participated in these activities and they were extremely happy to do so. The other activities coordinator spent her time in another lounge with other less able residents, facilitating activities on a 1 to 1 and small group basis. The practice adopted by both coordinators clearly demonstrates that the social and recreational activities offered are tailored to provide a very good level of stimulation on an individual and group basis. Residents were extremely positive about activities facilitated. Examples of comments include There is always something going on that I enjoy’; ‘I have plenty to do all day, everyday and interesting as well’. The care plans for three residents indicate that residents are being assisted to follow the lifestyle of their choice as discussed and agreed at the time of their assessment. All 5 residents spoken with said they are satisfied with their lifestyle at Rowles House. Evidence shows that family and friends visit regularly and they are always made welcome. ‘I have visited daily for the past year and I find staff very welcoming’, said a visiting relative. Equality and diversity within the service is being well promoted. Residents are encouraged and they are able to practice their religion and their culture, as they wish. There are 3 separate services offered monthly by various representatives of the local churches. 2 residents have severe dementia and arrangements are in place for them to receive individual communion monthly; 1 resident continues to attend a local church with their family. The menu seen provided for a nutritious and varied diet. Residents are consulted regularly regarding the menu and their taste and preference. Evidence shows alternative meals are provided if a resident does not like the meals on the menu. Comments from residents regarding the quality of food offered include: ‘Very good’, ‘I love the food and I can eat what I want’ and ‘Always adequate’. Discussion with the cook indicates she is knowledgeable about the dietary requirements of the residents. Rowles House Limited DS0000073249.V376185.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): Standard 16 and 18. People using the service experience good quality outcomes in this area. Residents can be assured that their concerns would be listened to and acted upon, and their welfare protected and promoted at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA tells us ‘Ensure that all residents and their families/representatives have a copy of our complaints procedure and understand it. The document is comprehensive with clear objectives and timescales indicated. Robust recruitment policy assures the safeguarding of vulnerable adults’. A copy of the complaints procedure is available to prospective and current residents. 3 of the 5 residents spoken to said that they are aware of the complaints procedure and would be able to raise a concern regarding any aspect of the service they receive. ‘I would speak with the manager or any of the staff but I am very happy here’, said a resident. Surveys from 5 residents indicate that they all know how to make a complaint. ‘My relative is being well looked after, can’t think of any incident that I can fault them’, said a visiting Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 16 relative. There have been no complaints received by the home since it begun operating on 28 January 2009. The Commission has not received any complaints regarding any aspects of the service. Staff members said that they know what to do if they receive a complaint. The whistle blowing policy is available to the staff team. The home also has procedure on safeguarding vulnerable adults. 7 members have not received training on safeguarding of vulnerable adults; however, documentary evidence indicates that arrangements are in hand for them to complete this specific training by 20 July 2009. With this in mind, a requirement is not being made. This standard will be fully met once the remaining members have completed their training. There have been no safeguarding matters arising since the home started operating. Rowles House Limited DS0000073249.V376185.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): Standards 19, 20, 21, 23, 24, 25 and 26. People using the service experience good quality outcomes in this area. People using the service are cared for in an environment that is homely, comfortable and safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We undertook a brief tour of the premises to include 8 bedrooms, 2 lounge/diners, conservatory, 4 bathroom/toilet/shower facilities and the kitchen. The standard of decoration and furniture and fittings in the lounge/diners and bedrooms is good. Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 18 The home was kept fresh and pleasant and a high standard of cleanliness was evident. Residents spoken to said that the home was always kept clean and bedrooms are well furnished and comfortable. They also said that they were happy with their bedrooms and that they are able to bring their personal possessions and belongings. Evidence of furniture, mobiles and other personal effect brought by residents was seen in the 8 bedrooms viewed. Since the transfer of this service to its current owner, the first phase of the refurbishment programme to include painting and decorating and carpet replacement has been completed. Few bedrooms with chipped paint and some of the bathroom/shower and toilet facilities require upgrading. The manager said that this is included in phase 2 of the refurbishment work, which would be completed by mid- October 2009. There is a large garden to the rear of the property, which is well maintained. It is accessible to residents and offers seating facilities and other garden furniture. Staff spoken to said that they had undertaken training in infection control Protective clothes and gloves and hand washing facilities are provided. There were no health and safety hazards noted. Rowles House Limited DS0000073249.V376185.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): Standards 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. Residents benefit from the care and support of a skilful and competent staff team, and the procedure for staff recruitment ensures their protection. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager tells us in the AQAA ‘As declared in our statement of purpose, we have experienced, competent and well trained staff’. Information from staff and duty rota for a month indicates that there are adequate numbers of staff available at all times to meet the needs of the resident group. In terms of skill mix, the staffing arrangements are appropriate to ensure that the needs of the people in residence could be met. 3 staff files were examined and these were found to have all the necessary documents including two written references for each employee; the Criminal Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 20 Records Bureau (CRB) checks are carried out before an offer of employment is made, in order to ensure the safety and protection of residents. Records show that all new members of staff undergo a programme of induction relevant to their work. ‘I had the opportunity to work with an experienced staff for the first 3 weeks and this was very helpful. It helped me understand the needs of service users and how they should be met’, said a new member. The manager has devised a training matrix and a rolling training programme is being arranged for staff. Residents and relatives spoken to said that there was a good staff team working in the home. Examples of comments from residents include: ‘Very pleasant and helpful lot’ and ‘I like them all’. ‘We visit almost daily and we think it is very pleasant and they are all very polite and friendly. We’ll be only too happy to place a relative at this home’, reflected 2 visitors. Of the 16 care staff including the deputy manager, 7 hold an NVQ level 2 or equivalent qualification, 3 members are currently working towards it and another 2 staff are scheduled to start the course in July 2009. The remaining 5 members are doing English as a secondary language before they could start their NVQ training. It is evident that training is being given a high profile and this investment in staff would ensure an improve quality of service delivery for residents. Rowles House Limited DS0000073249.V376185.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): Standards 31, 32, 33, 35, 36, 37 and 38. People using the service experience good quality outcomes in this area. People using the service can be assured that their health, safety and welfare are protected by the practices in place and the support they receive from an experienced staff team. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 22 The AQAA tells us ‘The registered manager is responsible, fit, qualified, competent, skilled and accountable’. The manager is registered with the Commission since October 2004. The service changed ownership in January 2009 and she continues to hold the registered manager’s post. She holds an NVQ level 4 in management and she has completed a 3 months training in Dementia; she is currently undertaking a 3 months course in Identifying/Implementing Training for Staff. Information from surveys, staff and residents indicates that management support is ‘very good’. All those spoken with said the manager is approachable, aware of all issues and makes sure agreed procedures are followed. Staff confirmed that they receive formal supervision regularly. Minutes are kept of both staff and residents meetings and outcomes from these are included in quality assurance monitoring. A quality assurance system (Annual survey) has been introduced to seek the views and experience of residents, their representatives and other stakeholders, with the view to improve the quality of service for residents. She hopes to complete the annual survey by September 2009. The director of care undertakes monthly visits to the home, in order to ensure that appropriate standards are being maintained. A sample of visits reports was viewed and is satisfactory. Staffs are not involved in the management of residents’ financial affairs. Records examined are in good order and are stored securely. Fire alarm checks and fire drills are carried out regularly and a record maintained. Risk assessments are completed for the building and grounds and these are reviewed as required. There are policies and procedures in place to ensure that the health, safety and welfare of residents and staff are protected and promoted. Mandatory training is provided but there are a few members that have not completed Moving and handling and First Aid. This is necessary for the safety of residents and staff. Rowles House Limited DS0000073249.V376185.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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 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 2 3 3 2 X 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 3 3 2 Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Not applicable. This is a new service. 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. 2. Standard OP21 OP38 Regulation 23 18 & 19 Requirement Upgrading work identified in standards 19 to 26 of the report must be implemented. Moving & Handling and First Aid must be completed by staff that has not done this mandatory training. This would ensure the safety of residents and staff. Timescale for action 15/10/09 15/09/09 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 OP7 Good Practice Recommendations The care and support given to each resident should be recorded on each shift; this would provide a comprehensive audit trail of how identified needs are being met. Rowles House Limited DS0000073249.V376185.R01.S.doc Version 5.2 Page 25 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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