Inspection on 13/09/05 for Rosedene

This inspection was carried out on 13th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rosedene 22/01/08

Rosedene 21/06/07

Rosedene 02/06/06

Rosedene 26/04/05

Rosedene 07/12/04

Rosedene 03/06/04

Rosedene 18/12/03

Similar services:

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Rosedene 141-147 Trinity Road Wandsworth Common London SW17 7HJ Lead Inspector Sharon Newman Unannounced 13 September 2005 10:30 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 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 and 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. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rosedene Address 141-147 Trinity Road Wandsworth Common London SW17 7HJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8672 7969 020 8672 3005 Mr T Lewis Miss Patricia Barber Care home with nursing (N) 67 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) of places Mental disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) Learning disability (LD) Dementia (DE) Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1- Learning Disability The home may provide accommodation and care for one named service user with a learning disability only. the category LD is to be removed once this service user is no longer accommodated at the Home. Date of last inspection 26th April 2005 Brief Description of the Service: Rosedene is a registered care home, presently registered for 67 nursing beds for service users over the age of 38 with needs including dementia and mental health. The property is located in Wandsworth Common, close to shops, pubs, the post office, bus routes, underground and over ground rail links. The home is on a busy main road, with parking to the front. The property comprises four large three storey terraced houses that have been joined together to form one care home. There are two passenger lifts between all floors. There is a garden to the rear, to the side of which there is a building where activities are provided. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 13th September 2005 and was conducted by one regulation inspector. The Manager was present throughout the inspection. Discussions also took place with the Registered Provider and the Catering and Domestic Services Manager. Records examined included care planning documentation, health and safety information and staff files. A tour was also taken of the premises. The pharmacy inspector has undertaken a separate inspection regarding medication matters at the home. The conclusions of his visit are included in the main body of this report. Four residents and three relatives were spoken to during the course of the inspection. Residents spoken to were positive about life at Rosedene. One relative said that ‘there is a lot of care and love at this home.’ Family members were very complimentary about the home and the care given to their relatives. The manager and the home staff made the inspector welcome and were helpful throughout the inspection visit. They were observed to have a good rapport with the residents. Redecoration of areas within the home has taken place since the last inspection visit and this is discussed in the Environment section of this report. A noticeable feature of the exterior of the building is the attractive hanging basket floral displays. The home has recently won an award for these in the ‘Wandsworth in Bloom’ competition. The Manager reported that the home has recently received a sticker for the high food hygiene standards at the home. One relative commented ‘this home is beautiful.’ A resident reported that they ‘feel safe here.’ What the service does well: The standards of meals remains good at this home and the kitchen is clean and hygienic. Residents and relatives were very complimentary about the food and the catering manager has a good knowledge of residents’ dietary needs, likes and dislikes. Staff were observed to have a good rapport with residents and relatives at the time of the inspection visit. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 6 The home has a comfortable and relaxed atmosphere. It is well maintained and clean and has an effective ongoing maintenance programme. The Registered Manager is approachable and she is liked and respected by residents and relatives. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4 Assessments of residents are thorough which allows a detailed care planning process to develop from this documentation. Good information is provided about the home in the Statement of Purpose and this allows residents to make decisions about their care. EVIDENCE: A Statement of Purpose is available at the home. This was examined in detail at the last inspection visit and found to have been updated this year. It contains information about choice, personal and health care, complaints, staffing and social activities. A Service User Guide is also in place which contains information about activities and health and social links available for residents. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 9 Residents are sometimes admitted for respite and there is a relevant policy in place. Terms and conditions of residence and a full assessment of need by a social worker were seen to be in place for a new resident. Relatives spoken to at this inspection visit commented on the ability of the home to meet residents’ needs. Residents were dressed appropriately on the day of inspection. A relative commented that their family member ‘always looks nice’ and that their clothes are well laundered. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 The health needs of residents continue to be adequately met and there is evidence of multi-disciplinary working with healthcare professionals. The home has arrangements for the storage, recording and auditing of medication and has access to a pharmacist for advice. Errors in recording and administration of medication and failure of medication supply were found that may have an effect on the health and welfare of residents although there had been improvement since the last visit. EVIDENCE: A new residents care plan was seen at the time of inspection and was found to contain personal information, a medical history and an assessment which Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 11 included details about the residents’ likes and dislikes. The assessment was based on activities of daily living and contained information about needs including: mobility, communication, and dietary information. A care plan was in place but had been drawn up by the residents’ previous care home and requires review by staff at Rosedene. A full review/assessment by the residents’ social worker was available. A falls risk assessment was also in place. Discussion took place with the manager about the need for information within the resident’s files to be more detailed. For example a full continence assessment could not be found and the documentation did not specify the type of incontinence diagnosed or whether specialist advice had been sought. Another residents’ file was found to contain information about doctor’s visits and records of the contact residents have had with health and social care professionals. The general and mental health information was seen to be detailed. Care plans were well organised and divided into sections making the information easily accessible. There is evidence in the care plans of multidisciplinary input from health and social care professionals and the Manager stated that the home receives support from the local specialist mental health team. One resident reported that they had felt unwell recently and were taken to the local hospital for a change of medication and now ‘felt better.’ The manager confirmed that risk assessments had not been drawn up for all residents requiring bed rail equipment. These must be put in place. A key worker system is in place and they are responsible for ensuring the updating of the care plans relating to specific residents. The written medication policies and procedures were found to be adequate on previous inspection and were not reviewed on this visit. All medications administered by staff along with the records relating to receipt, storage, administration and disposal of medication were examined. Two staff were interviewed and medication for twelve residents was counted and compared to the records of receipt and administration to monitor whether residents were administered their medication in accordance with the prescribers’ directions. From these observations and discussions two residents had missing entries on the administration record indicating administration/nonadministration of medication. From the quantity dispensed and the amount of medication in stock the medication had been given. One resident had been recorded as receiving their medication on the morning of 19th September 2005. From the balance of medication recorded on the administration record and the amount of medication in stock the morning medication had not yet been administered. The staff on duty said that the medication had been given. The change of dose of medication had not been recorded clearly for two residents making it difficult to assess if the medication had been administered as Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 12 directed. Differences were found between the amount in stock and the amount that should be in stock for one resident indicating that medication had not been administered correctly on one occasion. All residents except one did not receive any of their medication on 30th August 2005 as the supply had not been received from the pharmacy in time. This was because it was a bank holiday .One resident had not received one medication for one week, as the pharmacy had been unable to supply the medication. No records were seen of the action staff took to remedy the situation. Staff audit the medication in stock on a daily basis and record it on the administration record. The manager audits the administration records twice a month. No record was made of these audits. All other records were completed accurately and medication was stored safely and under the appropriate conditions ensuring the health and welfare of residents are protected. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Residents receive a wholesome and balanced diet in pleasant surroundings. Dietary needs continue to be well met and food looks well prepared and nutritious. Relatives are encouraged to maintain contact with residents. EVIDENCE: An activities co-ordinator is employed by the home. The manager reported that they are currently reviewing the activities offered to residents to ensure they all have a chance of being included in the activities. A new timetable has been drawn up which includes activities such as: art and crafts, bingo, cooking classes, quizzes and singalongs. The manager reported that some residents had attended church on the morning of the inspection visit. There is an Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 14 activities room for the use of residents which is situated in the rear garden of the home. A new resident spoken to said that they sometimes like to go for walks in the garden and around the home. They were observed to be watching television in one of the lounge areas at the time of the visit. Regular residents meetings take place which are held by the activities coordinator and are fully recorded. Relatives and residents spoken to indicated they are given choice at the home in relation to dietary needs and what clothes to wear. Residents were observed to access all communal areas and those who wish to smoke may do so in the conservatory. One relative commented that they can choose to participate in their family members’ care. A garden party for residents was held in July and family members were invited. Residents and relatives commented positively about this event. All the relatives spoken to reported what a good time they had at this event. A hairdresser visits the home regularly and was seen visiting on the day of inspection. Residents were seen having their hair washed and cut in the hairdressing area. Feedback from relatives and residents was very positive regarding the food served at the home. As reported at the previous inspection visit menus demonstrate that residents have a choice of two hot meals and two dessert choices at lunchtime. The catering manager has a very good knowledge of individual residents dietary needs, likes and dislikes. She stated that the menus change according to the seasonal choice available. The catering manager reported that a choice of water, juices, tea, coffee, milkshakes, yoghurt drinks and hot chocolate are all available to residents throughout the day. Tea, coffee and juice drinks are served with all meals and a choice of fresh fruit is available daily. One resident said they liked the food and they were offered a choice of menu. Two relatives commented that the ‘food is lovely’ and their relative always has a ‘good sized portion.’ They also reported that there are always clean tablecloths on the table. The manager reported that the dining tables have been set at an angle to ensure there is less of an institutional feel. Correspondence was seen to show that the home has been awarded a Food Safety Sticker award for the standard of their food hygiene. The home has a pet cat which helps to lend a homely feel to the environment. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The home has policies and procedures in place to protect residents. However, complaints need to be fully recorded to ensure residents are not placed at risk. EVIDENCE: The home has adopted the London Borough of Wandsworth’s Protection Of Vulnerable Adult Procedures and a copy of this was available at the home. They also have a whistle blowing procedure and an organisational abuse policy in place. A staff member spoken to demonstrated a good knowledge of the importance of reporting any suspected abuse but indicated they had not attended any abuse awareness training for a considerable time. All staff must receive up-todate training in this area. There is a complaints policy at the home and a complaints log is kept. However, one recent complaint was not recorded and another complaint did not have a clear outcome documented. All complaints must be fully recorded and outcomes must be detailed to ensure a clear audit trail. Four relatives spoken to at this inspection visit commented that as soon as issues are brought to the attention of the Manager they are addressed. They all reported that they currently had no complaints about the home. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 16 Risk assessments in relation to bedrail equipment needs to be put in place to ensure the health and safety of residents. Two relatives stated that they felt the home was ‘a safe environment’ for their family member. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 25, 26 The standard of the environment within this home remains good providing residents with a comfortable place to live. The standard of maintenance of the premises also remains good. The ongoing programme of refurbishment has improved parts of the home making them more attractive and homely. EVIDENCE: This home has accommodation that is arranged over three floors and has two passenger lifts which serve the floors. The exterior of the home was attractively decorated with floral displays in hanging baskets on the day of Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 18 inspection. The Manager reported that they have recently won an award for these displays in the ‘Wandsworth in Bloom’ competition. No maintenance issues were identified at this inspection visit. The manager reported that areas within the home have been refurbished since the previous inspection visit. This includes the dining room and the first floor landing. The redecoration has greatly improved these areas making them appear more attractive and homely. The manager reported that new flooring is to be laid in the ground floor lounge and the ground floor corridor is to be redecorated. A rolling maintenance programme is in place and a full time maintenance person is employed at the home. The catering and domestic manager said they were just putting the finishing touches to the newly decorated areas by adding mirrors and pictures. She stressed the importance of providing an attractive environment for the residents. A resident commented that they liked the redecoration that has taken place. The home was clean, hygienic and free from offensive odours on the day of inspection. Three cleaning staff are employed by the home and one is responsible for each floor of the home. One relative commented on the ‘spotless kitchen.’ Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 29, 30 Staff demonstrate a caring attitude to the residents. Staff training needs to be kept up-to-date to ensure that residents are not put at risk. Recruitment checks are thorough. EVIDENCE: Staff were observed to interact well with residents throughout the inspection visit. Relatives spoke highly of the staff. One relative commented that ‘the staff are lovely’ and that they have ‘time for the residents.’ A staff member spoken to said that they felt ‘well supported’ by the Manager and the Director. They said they were happy at the home and enjoyed working there. Although some staff training has taken place there was not sufficient evidence to suggest that all staff have received up-to-date training in mandatory areas such as moving and handling, food hygiene, first aid and health and safety. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 20 Up-to-date training also needs to be in place in the areas of abuse awareness and medication. The Manager reported that some staff meetings have been taking place but have not been recorded. Regular staff meetings should be held and fully recorded. Four staff files were sampled at this inspection visit and were found to contain all required information apart from up-to-date photographs of staff members. These need to be put in place. Criminal record checks and two references had been obtained for the four staff members whose files were seen. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 38 The manager continues to provide clear direction and leadership. The health, safety and welfare of residents is promoted and protected. Staff supervision needs to take place to ensure they are supported in their roles. EVIDENCE: Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 22 The manager is currently completing the Registered Managers Award (RMA) and has been working at the home for many years. One relative commented that the manager is ‘very lovely’ and reported that residents are given choice in their day-to-day lives. The manager retains overall responsibility for care at the home and the Catering and Domestic manager continues to oversee all catering and cleaning arrangements at the home. Regular management meetings are held and minuted, topics discussed at the last meeting included: bed rail equipment, activities, staff supervision and training, quality assurance and fire training. The manager reported that regular staff supervision is still not in place. Staff must receive one-to-one supervision at least six times a year. However, it is recognised that that this is being addressed and paperwork was seen to have been drawn up for staff supervision sessions. A Quality Assurance system is in place and the views of residents were sought last year using a questionnaire. The questionnaire has been devised by the home to seek the residents’ views about life at the home including: admission, catering and food, personal care, daily living, premises and management. The manager stated that a quality assurance audit was going to be undertaken again this year. Discussions took place that the results would need to be collated and the findings presented in a report format for the residents. A questionnaire was seen and the manager reported that this is to be given to staff to seek their views about the home. Health and Safety checks were seen to be taking place at the home. Up-todate certificates were seen in respect of: gas safety, electrical installation and portable appliance checks. A legionella risk assessment is in place. Fridge and freezer temperatures are recorded daily and hot water temperatures are checked weekly and remain within safe limits. A recent fire inspection has taken place which was conducted by the London Fire and Emergency Planning Authority. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 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 x 2 3 3 3 4 3 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 3 x x x x 3 3 Score Standard No 7 8 9 10 11 Score 2 3 2 x x Standard No 27 28 29 30 x 3 2 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 2 x 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 3 34 x 35 x 36 2 37 x 38 3 Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 OP7 OP9 Regulation 15 (2) 13 (2) Requirement The Registered Person must ensure that all care plans are reviewed monthly. The Registered Person must ensure: 1. that the administration/nonadministration of all medication is recorded accurately. 2. that any contact with health professionals and subsequent action is recorded. 3. that arrangements are in place to ensure that an adequate supply of medication is available for all service users and where a supply is not available action of staff to remedy the situation is recorded. 4 that all changes to medication are recorded clearly on the administration record. 3. OP16 17 (2) Schedule 4 12, 13 (4) The Registered Person must ensure that a full record is kept of all complaints and outcomes are fully recorded. The Registered Person must ensure that individual risk 01/10/05 Timescale for action 01/11/05 03/10/05 4. OP18 01/10/05 Page 25 Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 5. OP29 19 (1) Schedule 2 18 (1) 6. OP30 7. OP36 18 (2) assessments for cot side equipment are put in place. The Registered Person must ensure that all staff files contain recent photographs of staff members. The Registered Person should ensure that staff training is upto-date. Refresher training must be provided for staff as required with regard to Medication, Moving and Handling, First Aid and Food Hygiene. (Timescale of 01/08/05 not met). The Registered Person must ensure that all care staff receive one to one supervision six times a year (pro-rata for part-time staff). All staff responsible for facilitating such sessions must receive suitable training. (Timescale of 30/06/05 not met). 01/12/05 01/12/05 01/11/05 8. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP28 Good Practice Recommendations It is recommended that a record be made of the audits of administration records done by the manager. It is reccommended that regular staff meetings take place and are fully minuted. Rosedene G54-G04 S19117 Rosedene V242708 130905 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 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. 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