Inspection on 24/11/05 for Rosedale

This inspection was carried out on 24th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosedale 17/07/08

Rosedale 18/07/07

Rosedale 14/09/06

Rosedale 25/04/05

Rosedale 07/10/04

Rosedale 04/05/04

Rosedale 28/11/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Rosedale 1 Wide Way Mitcham Surrey CR4 1BP Lead Inspector Liz O`Reilly Unannounced Inspection 24th November 2005 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rosedale Address 1 Wide Way Mitcham Surrey CR4 1BP 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) 0208 679 0752 Mr Kanagasabai Wignarajah Kailasananthan Mr Kanagasabai Wignarajah Kailasananthan Care Home 12 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (12) Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: Rosedale is an extended domestic property which provides accommodation and care for up to twelve older people, three of whom may have dementia or suffer from mental illness. The property is in keeping with neighbouring houses and is not identifiable as a care home. The home is close to public transport, leisure facilities, a group of local shops and places of worship. Accommodation is provided over two floors. The shared areas of the home are on the ground floor. The home is staffed twenty four hours a day. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one regulation inspector over four and a half hours on 24th November 2005. The inspector was able to speak with six residents and the registered owner/manager. A sample of records were also examined. What the service does well: What has improved since the last inspection? What they could do better: Further care needs to be taken to ensure that all the appropriate information is available prior to staff commencing work in the home. Two references must be sought by the home and kept on file along with a current photograph. The pre admission care management assessment must be obtained before any resident moves into the home. A clear record of any money held on behalf of residents must be in place. Plans need to be made to replace worn furniture in bedrooms and to install appropriate locks to bedroom doors. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 6 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. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 7 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 Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 Residents are provided with information on the home through the Service User Guide and the Statement of Purpose. The lack of care management assessments means that staff may not have all the relevant information to provide appropriate care to each person as soon as they move into the home. Residents can make trial visits to the home before moving in. EVIDENCE: The Statement of Purpose and Service User Guide give information to prospective and present residents on what they can expect from the home. To make sure staff have all the information necessary to provide care to new residents a copy of the care management assessment must be available in the home before any new person moves in. Residents can try out the home by visiting or staying overnight before they make a decision to move in. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The strengths and needs of each resident are set out in individual care plans. The health care needs of residents are met. The health and welfare of residents is protected by well managed medication systems. EVIDENCE: Risk assessments and a care plan are produced for each resident. Information on care files includes a personal profile setting out a brief life history and the likes and dislikes of individuals. This information provides staff with good information on which to base individualised care. Good daily records are maintained for each resident. Care plans are reviewed monthly. The care planning has improved since the last inspection. All residents are registered with local GPs. All residents receive regular dental, optical and chiropody checks. Staff can call upon community psychiatric services for advice if required. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 10 Records of medication are well maintained. Medication is stored safely. All staff have received training on the management of medication. These records and the training provided assist in ensuring the health and welfare of residents. Residents confirmed that staff respected their privacy and treated them well. Staff were observed to offer assistance and advice in a discreet and sensitive manner. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 13 Residents take part in a variety of activities. Staff support residents to maintain contact with family and friends. EVIDENCE: A number of residents take part in a variety of activities outside the home. These include attendance at day centres, clubs, church lunches, shopping and using the public library. One resident arranges their own regular day trips. Activities within the home include quizzes, cards, dominoes and reading. Residents confirmed they joined in activities if they wished. Certain residents said they preferred to occupy themselves watching TV or reading in their rooms and chatting to staff. Residents gave positive comments on the food provided. A four week menu is in place with alternatives available at each meal time. Residents can get drinks and snacks at any time. Residents said that mealtimes are flexible and staff make sure if a resident is out a meal will be available when they get back. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints system ensures that any complaint made by a resident or their representatives are recorded along with outcomes. Procedures are in place for the reporting of any suspicion or allegation of abuse. EVIDENCE: A clear procedure for recording any complaint about the home is in place. Any complaint is recorded along with details of the investigation and outcomes. No complaints have been received by the home or the CSCI about this service since the last inspection. Residents spoken to said that if they had any concerns they would speak to the manager or a family member. Residents expressed confidence in the staff to help them if they were not happy with something in the home. All staff have received training on protecting residents from abuse. Staff are aware of their responsibilities to report any suspected abuse to the appropriate persons. The home has its’ own procedure for protecting residents from abuse and in addition a copy of the local authority procedure is available to staff. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Residents are provided with a comfortable, homely environment. However plans need to be made for the replacement of worn bedroom furniture and for the installation of appropriate locks on bedroom doors. The home was found to be clean and tidy. EVIDENCE: The ground floor bathroom has been redecorated since the last inspection of the home. The furnishings in communal areas are comfortable and appropriate to the needs of the residents. Bedroom furniture is showing signs of wear and tear. A programme for the gradual replacement of worn furniture needs to be in place. A gradual programme for the installation of locks to bedroom doors needs to be started. All residents should be offered a key to their bedroom with staff holding a copy or master key for use in an emergency. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 14 The home was found to be clean and tidy during this visit. The home has a small laundry room with appropriate equipment. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Sufficient staff are on duty to meet the needs of residents during the day. Further records need to be maintained to show that sufficient staff are available at all times at night. The information held on staff files needs to be improved. EVIDENCE: A minimum of two staff are available in the home at any one time day or night. At night one member of staff sleeps on the premises with another member of staff awake through the night. A record of any instances where the person sleeping in has been called out must be kept in the home. This record must include the length of time the second person was needed and the reason for them being called. This will ensure that the staffing levels at night remain appropriate. Staff are taking part in or have completed NVQ training levels two to four which ensures that residents are cared for by a well informed staff group. Arrangements have been made for four of the staff group to attend a mental health awareness course in December 2005. Training relating to the health and safety of residents is carried out on a regular basis. Before staff start working in the home Criminal Records Bureau checks are carried out. The manager must ensure that at least two written references are sought for each member of staff. These references must be held on the staff file. An up to date photograph of each member of staff must be held on file. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 16 Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35, 36 & 38 Residents are given opportunities to influence the way the home operates. Further work needs to be carried out on the quality assurance systems. The record of residents money needs to be more detailed. Staff carry out regular checks to ensure the health and safety of residents. EVIDENCE: Residents meetings are held on a regular basis and staff also meet with some residents on a one to one basis. This allows residents the opportunity to voice their views about the way the home is run. Staff keep a record of all meetings and take action to implement changes. To make sure the home is meeting it’s stated aims and objectives the manager has commenced an annual review of the service. This includes seeking the views of residents and others connected with the home via questionnaires. Once this review is completed a copy of the report must be sent to the CSCI. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 18 The results of the residents survey must also be made available to the present and any prospective residents. Residents can deposit small amounts of personal money with the home for safekeeping. The manager must make sure that a clear record of all money deposited and any expenditure is maintained in the home. Staff are provided with regular one to one supervision which ensures that staff are supported and work in line with the aims and objectives of the home. Training on moving and handling, food hygiene and first aid are supplied to staff to ensure the health and safety of residents. The home keeps a record of any accidents along with details of actions taken and outcomes. Regular checks are carried out on the fire alarm system, the stairlift, parker bath and the temperature of hot water. These checks assist in ensuring the health and safety of residents, staff and visitors to the home. Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 2 x 2 3 x 3 Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) Requirement The Registered Person must ensure that a copy of the Care Management assessment is sought prior to any resident being admitted to the home. The Registered Person must produce a programme for the replacement of worn bedroom furniture. The Registered Person must produce a programme for the installation of suitable locks to bedroom doors. The Registered Person must ensure that a record of all instances where staff sleeping on the premises are called upon during the night is maintained in the home. The Registered Person must ensure that two references are sought and held on file for each member of staff. An up to date photograph of each member of staff must be held in the home. The Registered Person must provide a copy of the report DS0000027228.V272325.R01.S.doc Timescale for action 01/02/06 2 OP19 16(2)(c) 23(2)(c) 12(4)(a0 01/02/06 3 OP19 01/02/06 4 OP27 18(1)(a) 01/02/06 5 OP29 19(b)(c) 01/02/06 6 OP33 24(2) 01/05/06 Rosedale Version 5.0 Page 21 7 OP35 17(2) Schedule 4 (9) produced following the annual review of the service. The Registered Person must ensure that individual financial records for residents show all transactions. 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 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 Rosedale DS0000027228.V272325.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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