Inspection on 02/06/06 for Rosedene

This inspection was carried out on 2nd June 2006.

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 13/09/05

Rosedene 26/04/05

Rosedene 07/12/04

Rosedene 03/06/04

Rosedene 18/12/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 HOMES FOR OLDER PEOPLE Rosedene 141-147 Trinity Road Wandsworth Common London SW17 7HJ Lead Inspector Sharon Newman Unannounced Inspection 10:00 2nd June 2006 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 Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 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. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rosedene Address 141-147 Trinity Road Wandsworth Common London SW17 7HJ 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) 020 8672 7969 020 8672 3005 Mr T Lewis Miss Patricia Barber Care Home 67 Category(ies) of Dementia (67), Dementia - over 65 years of age registration, with number (67), Learning disability (1), Mental disorder, of places excluding learning disability or dementia (67), Mental Disorder, excluding learning disability or dementia - over 65 years of age (67) Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 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. 13th September 2005 Date of last inspection Brief Description of the Service: Rosedene is a registered care home, presently registered for 67 nursing beds for service users 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. The fees range from £616.79 to £1670.25 per week. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 2nd June 2006 and was conducted by two regulation inspectors and a pharmacy inspector. A follow-up inspection by the pharmacy inspector took place on 20th June 2006 and these findings are included in the body of this report. The manager was present throughout the inspection visit. Discussions also took place with the registered provider and the quality assurance manager. Records looked at included medication records, care planning documentation, health and safety information and staff files. A tour was also taken of the premises. Surveys were left at the home to be handed out to relatives and residents. Two were returned from relatives and three from health/social care professionals before completion of this report. Residents were spoken to during the inspection visit and were largely positive about life at the home. One resident reported that they were ‘very happy’ here and that they ‘loved’ their room. One relative commented that the home provides an excellent service in ‘all areas.’ What the service does well: What has improved since the last inspection? Risk assessments are now in place for those residents who need to have bed rail equipment. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 6 Significant improvement has been made in the recording and auditing of medication handling and administration. Residents are able to self- administer their medication after an assessment The redecoration schedule continues especially in the corridors, which helps to improve the environment for the residents. Some bedroom furniture, a new TV and DVD for lounge have been purchased. All staff files sampled were seen to include photographs of the staff members. Although some staff training still needs to take place it is recognised that this area is improving. What they could do better: Service Users Guides need to be issued to all residents so that they are aware of the services offered at the home. Care plans would benefit from more detail about individuals needs to ensure that their needs are met. Regular updating of this documentation should also take place. Risk assessments need to be in place for all residents and must be up-to-date to ensure that all risks have been considered. The home needs to improve the recording of actions taken following audits of medication and to continue to monitor the administration of medication. The double glazing unit with condensation in a residents’ room needs to be replaced or repaired. Also the missing curtains in the ground floor bedroom need to be replaced to ensure the residents privacy and dignity is maintained. Staff meetings should take place more regularly. Improvements still need to be made in staff training to ensure records are available to provide evidence that they have up-to-date knowledge in areas such as moving and handling, first aid and food hygiene. All staff need to have a contract in place for their current position to ensure that they are aware of their terms and conditions and the change in job description. The frequency of staff one to one supervision needs to improve to allow staff to be given direction and support in their roles. The Commission for Social Care Inspection must be informed of all issues affecting the health and safety of residents including medication errors. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 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 Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. 2. 3. 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Not all service users have been provided with service users guides or contracts and this does not help them to make an informed choice about living at the home. Assessments need to contain more detail to ensure that residents’ needs can be met. However most residents spoken to were happy living at the home. EVIDENCE: A Service User Guide is in place which contains information about activities and health and social links available for residents. However all residents need to be given a copy of this guide to ensure they are aware of the services on offer at the home. Most of the files looked at contained a contract of residence, however one file did not contain this documentation. Contracts must be in place for all service users in a format that they can understand to ensure they are aware of the terms and conditions of the home. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 10 Assessments were in place for all service users in the files seen. One assessment had been updated since the individuals’ admission ten years ago. The manager has just reviewed the key worker system and she reported that it was now working more effectively. A resident said that they knew who their key worker was and that they found them helpful. Another resident reported that they ‘really enjoyed living here as the food is good and the staff are nice.’ One relative said that the home provides an excellent service in ‘all areas.’ Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. 8 .9. 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health needs of residents continue to be met and there is evidence of multi-disciplinary working with healthcare professionals. The home responded positively to medication incidents with improvement in monitoring and handling of medication. EVIDENCE: The care plans contained a lot of information and the life history sections were very informative. They help the reader to build up a good picture of the resident and their life, likes and dislikes. They were also observed to include detailed daily living profiles. The care plans were separated into twelve sections covering personal care needs, mobility, safety, communication, social and emotional needs, mental status, sexuality and night care. They noted residents’ needs and were detailed with the exception of section on sexuality, which was not completed appropriately in most cases, and this must be addressed to ensure individual’s needs are recorded in full so they can be met. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 12 However, one care plan did not contain sufficient information about a residents’ particular need and this was discussed with the manager and quality assurance manager at the time of the inspection. Another care plan stated ‘no problem’ in the section about sleeping and ‘doubly incontinent to have regular toileting regime’ in the continence section. This information needs to be more detailed and include more specific information about the residents’ sleeping habits and the continence issue. It did not specify what specialist advice has been sought, type of incontinence and what action plan was to be put in place. The manager reported that they were going to implement training in care planning for the staff so that they are more aware of the importance of putting sufficient information in care plans. All care plans need to contain enough information to ensure that residents’ needs can be met. One resident and their relative confirmed that they are involved in developing care plan and in reviews and this allows the residents needs and views to be taken into account. Although many risk assessments were seen to be up-to-date some had not been reviewed regularly and one risk assessment did not apply to the resident anymore. All risk assessments should be regularly updated and any out-ofdate information should be archived. Also one risk assessment was observed to contain information about at least three different risks and this was confusing. It was discussed with the manager that each risk should be considered separately to ensure the information is easy for staff to follow and also demonstrate that risks have been fully considered. A risk assessment was seen to be in place for a resident who requires bed rail equipment. However, it was discussed with the manager that the home should consider putting documentation in place to demonstrate the involvement and agreement of relatives, the resident and health/social care professionals. This will help show that all parties have been consulted and are in agreement. There was evidence in the care plans of multidisciplinary input from health and social care professionals and the home receives support from the local specialist mental health team. A health/social care professional commented that the home provides ‘good care in general.’ Another reported that the ‘clients care’ was excellent. Two residents reported that they enjoyed going out, one said they were glad they had the choice to go out alone. Risk assessments were in place for one individual who goes out alone. The registered provider and manager displayed a very open manner in discussing a recent medication issue involving a resident. Full written details of the issue were supplied to the inspection team on the day of the inspection. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 13 However, it was discussed with the registered provider and the manager that the Commission for Social Care Inspection must be informed of all incidents which affect the health and welfare of the residents. All records relating to receipt, storage, administration and disposal of current medication were examined. The manager and three staff member were interviewed. A sample of the current medication in stock was compared to the current records and counted and compared to the amount that should be in stock. All medication was stored securely and in the correct conditions. All medication is supplied in appropriately labelled containers. A running total is maintained of the amount of medication in stock. This provides an audit trail to check whether medication has been given correctly. Four residents are self-medicating one or more of their medication. Risk assessments are in place. Following an incident involving medication not being given correctly, audits are done weekly on a sample of records and medication. On the first day of the visit the administration of medication had not been recorded accurately for six residents. The amount of medication in stock did not agree with the amount that should have been in stock in nine instances. These issues had been picked up by the audit and action was being taken to remedy these issues. This included staff training and new procedures for checking in and administering medication. As these actions had only just been introduced it was agreed that a further visit would be undertaken to review the effectiveness of the actions taken. The date of receipt had not been recorded for any of the current monthly supply of medication. One resident had not been given their medication as directed for three weeks. This was highlighted on the first day of the visit. These issues would be followed up on the second visit. On the second visit, two audits and been done by the manager on a sample of residents. This highlighted only two instances where the amount of medication in stock did not agree with the running total of medication on the administration record. No records were seen of the outcome of any investigation in to these incidents. The manager said that staff had been spoken to but it was difficult to draw any conclusions as to why there was a discrepancy. The residents not included on the audits were checked on the day of the visit. All receipt and administration of all medication had been recorded fully and alterations to medications clearly recorded. The current stocks of medication all agreed with the amount that should be in stock indicating that all current Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 14 medication had been given as directed by the prescriber unless other wise clearly recorded. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 15 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. 14. 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. 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. However there is a lack of staff interaction with residents and more activities should be encouraged. EVIDENCE: There is an activities room in the garden and residents who wish to take part in painting, drawing and listening to music can attend sessions led by the activities co-ordinator. Many residents were observed to be sitting in chairs in the lounge areas and it was noted that there was little interaction between the staff and residents. A discussion took place with the manager that staff should be encouraged to interact more with the residents and that they should encourage residents to take part in activities. One health/social care professional reported that the home could improve it’s service by ‘providing more escorts for clients wishing to go into the community.’ One relative commented that they would like to see greater opportunities for their family member to have trips out of the home. Another relative said that the residents Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 16 are ‘not encouraged to do anything’ and that life at the home could improve by getting residents ‘active in different things.’ One resident said that they have plenty to do at the home, they participate in Bingo, colouring and drawing and proudly showed some artwork displayed on wall in corridor by office. Two residents commented that they don’t join in with activities at the home but have their own leisure pursuits in their bedrooms. The manager reported that the annual summer garden party is going to take place in July. A hairdresser visits the home regularly to enable those residents who are unable or do not wish to leave the home an opportunity to have their hair done. As reported in the previous inspection report the home has obtained a Food Safety Sticker award for the standard of their food hygiene. Feedback from residents about the food at the home was largely positive. There is a choice of two hot meals and two dessert choices at lunchtime. Tea includes a light snack and the supper offered is fruit and sandwiches. The quality assurance manager continues to have very good knowledge of individual residents dietary needs, likes and dislikes. Residents’ comments regarding the food included ‘lunch was good’, ‘I like the food’, ‘I would prefer a fried breakfast’ and ‘the food is always good’. . Residents sit in dining rooms or lounges on each floor for meals and some residents have meals in their bedrooms. One resident confirmed that they have meals in their bedroom, that meals are hot enough and that they are served on an appropriately laid tray. A relative reported that the food is ‘good and varied.’ Visitors were observed to be welcome and were offered drinks on arrival at the home. One resident said that they liked the home and he had ‘nice clothes and nice food’ here. A relative commented that the resident’s ‘laundry is always done well.’ Residents are given choice at the home in relation to dietary needs and what clothes to wear. Those who wish to smoke may do so in the conservatory area or the garden. It was noted that one resident who had requested to move bedrooms had been supported to do this. This resident said they were very happy about this and proudly showed the inspection team their new bedroom. The home has a pet cat, which helps to lend a homely feel to the environment. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 17 Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has policies and procedures in place to protect residents and is seen to follow these procedures. However as not all staff have received training in abuse awareness this may place residents at risk. EVIDENCE: There is a complaints policy at the home and a full log of all complaints and outcomes is kept. This has improved since the previous inspection and ensures that there is a clear audit trail. The home follows 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. One staff member spoken to demonstrated a good knowledge of the importance of reporting any suspected abuse. Another staff member was not clear about this issue and had not received up-to-date training in abuse awareness. Staff records also indicated that not all staff were up-to-date with this training. All staff must receive training in this area to ensure residents are not placed at risk. One relative and resident spoken to were aware of how to make a complaint although they had not needed to. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 19 Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 20 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. 24. 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. This home provides residents with a comfortable place to live. The standard of maintenance of the premises also remains good. The ongoing programme of refurbishment continues to improve 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 that serve the floors. The exterior of the home was again attractively decorated with floral displays in hanging baskets on the day of inspection. The quality assurance manager said that the rolling programme of maintenance and decoration continues particularly in the corridors and that new furniture and wardrobes had been bought for residents. She reported that a new floor has been laid in the lounge. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 21 Bedrooms have linoleum flooring, single bed, wardrobe, chest of drawers and a wash hand basin. Some bedrooms included pictures and had been personalised by the individual while other bedrooms were very bare. A doubleglazing unit in one of the resident’s bedrooms was seen to have condensation and this must be replaced or repaired. Two residents spoken to reported that they liked their bedrooms. Those bedrooms that are shared by two residents have a small screen to provide some privacy for them. It was discussed with the manager that whether residents are asked if they wished to share a room prior to admission as one resident said they were unhappy living with the individual they shared their room with. The name plates on two bedrooms were missing and the manager reported that this can be a frequent occurrence, consideration should be given to different ways to label residents bedrooms. The home was clean, hygienic and free from offensive odours on the day of inspection. One member of cleaning staff is responsible for each floor of the home. A relative commented that the rooms are very clean and kept well. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 22 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff training is improving however, this still needs to improve to ensure residents needs can be fully met. Contracts need to be up dated to ensure that they include details of the individual’s new role. EVIDENCE: Residents spoken to made positive comments about the staff, one resident spoken to stated that they thought the staff were ‘lovely.’ It was discussed with the manager that although staff meetings are taking place they should be held more frequently. Five staff files were looked at and contained the required information apart from two which did not contain updated contracts for staff members who have now been employed in different roles at the home. Training records for the same five staff members were looked at and these indicated that they had all undertaken training in first aid, one had obtained a NVQ qualification, four had training in moving and handling, one had training in mental illness and one had care planning training. Two members of staff had watched a video on abuse awareness and been given a handout on the subject. It is recognised that staff training is improving and much emphasis has been placed on this issue by the home. The quality assurance manager reported that Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 23 training is now a priority. However it was discussed with the manager that the home needs to ensure that all staff are up-to-date with training especially in mandatory areas such as moving and handling and also abuse awareness, care planning, mental health and dementia care. This will help to ensure that residents are not placed at risk and that their needs can be met. One staff member reported that they had undertaken abuse awareness training this year and moving and handling training last year. Another staff member said that they had done training in abuse awareness, moving and handling, health and safety and food hygiene. One staff member reported that they were doing the NVQ Level 2. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 24 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): 31. 33. 35. 36. 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager continues to provide clear direction and leadership. Staff supervision is also improving, however it still needs to increase in frequency to make sure that staff have the direction and support they need. EVIDENCE: The manager reported that they have now obtained the NVQ level 4 in care. She is experienced, has been at the home for many years and has a good knowledge of the residents and their needs. A staff member said that she was ‘very nice and supportive.’ One health/social care professional commented that the manager keeps their team informed of changes in the clients mental health. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 25 A staff member reported that the quality assurance manager was ‘very nice’ and ‘approachable and helpful.’ There is a good staffing structure and clear lines of accountability at the home. The manager retains overall responsibility for care at the home. A staff member has been promoted to the position of deputy manager at the home since the last inspection visit. The catering and domestic manager has been promoted to the post of quality assurance manager and also continues to oversee all catering and cleaning arrangements at the home. She commented that she is enjoying her new responsibilities very much. Quality assurance continues to be a high priority in the home. The quality assurance manager reported that the home was trying to ensure that staff, residents and relatives were more involved in life at the home. She said that a sample of residents and relatives are given questionnaires quarterly and a report is then drawn up to show their views about life at the home. This helps to make sure that their views are taken into consideration. The residents survey includes questions about the admission process, catering and food, personal care, daily living, premises and management. The yearly ‘quality assurance report’ contains information from many sources including: residents views taken from their meetings and from the surveys they have filled in, relative comment cards, the maintenance reports and the house check reports. Planned improvements are then put in place from the results of all the information. Residents monies were observed to be held separately and the manager was observed issuing money to residents on the day of inspection. Records identified that two members of staff received supervision, however this still needs to increase in frequency to ensure that all staff are receiving supervision at least six times a year. Health and safety checks were all in order. Up-to-date certificates were seen in respect of: gas safety, electrical installation and portable appliance checks. A legionella risk assessment is in place. Evidence was seen to show that fire drills take place monthly and the fire points tested at this time are clearly documented. Fridge and freezer temperatures are recorded daily and hot water temperatures are checked weekly and remain within safe limits. As reported in the ‘Health and Personal Care’ section of this report the Commission for Social Care Inspection must be informed of all incidents that affect the health and welfare of the residents. Also, a health/social care professional stated that the home could improve practice by informing them of any incidents involving their clients as soon as possible after the event. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 26 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 X 2 X 3 Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 5(2) Requirement Timescale for action 01/08/06 2. OP2 5(1) 3. OP7 15 (2) The Registered Person must ensure that all service users are given a copy of the Service Users Guide. The Registered Person must 01/08/06 ensure that all service users are supplied with terms and conditions/a contract. The Registered Person must 01/08/06 ensure: 1. That all care plans are reviewed monthly. (Timescale of 01/11/05 not met.) 2. That care plans contain sufficient information to ensure that service users needs are met. 3. Risk assessments are detailed and up-to-date. The registered person must ensure records are made of action taken and outcomes when discrepancies are found in the recording of medication. The Registered Person must ensure that all staff are trained DS0000019117.V293920.R01.S.doc 4. OP9 13 (2) 20/07/06 5. OP18 13(4&6)1 8(1)c 01/08/06 Rosedene Version 5.1 Page 28 6. OP24 23(2)b & d 19 (1) Sch 2 7. OP29 8. OP30 18 (1) 9. OP30 18 (1) 10. OP36 18 (2) 11. OP33 37 in recognising and reporting abuse. The Registered Person must ensure that the double-glazing unit with condensation is replaced or repaired. The Registered Persons must ensure that all staff files contain contracts of employment which reflect the terms and conditions of their current role. The Registered Persons should ensure that staff training is upto-date. Refresher training must be provided for staff as required with regard to moving and handling. The Registered Person must ensure that staff receive training in the areas of mental health and dementia care. The Registered Persons 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. (Timescales of 01/04/05 and 01/11/05 not met). The Registered Person must ensure that the Commission for Social Care Inspection is notified of all events that affect the well being and safety of the service users. 01/08/06 01/07/06 01/09/06 01/10/06 01/08/06 01/07/06 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 Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 29 1. 2. 3. OP9 OP19 OP28 It is recommended that staff have access to up to date information regarding medication in mental health Consideration should be given to different ways to label residents bedrooms. The registered provider should consider holding staff meetings more regularly. Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 30 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 Rosedene DS0000019117.V293920.R01.S.doc Version 5.1 Page 31 - 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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