Inspection on 21/06/07 for Rosedene

This inspection was carried out on 21st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 02/06/06

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 Davina McLaverty Unannounced Inspection 10:00 21st June & 5th July 2007 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.V343103.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V343103.R02.S.doc Version 5.2 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 terry@rosedene-nursing.fsbusiness.co.uk 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.V343103.R02.S.doc Version 5.2 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. 2nd June 2006 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.V343103.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit inspection took place over one and a half days by two regulatory inspectors and a pharmacy inspector. Both managers were present on the first day of the inspection visit. On day two the quality assurance manager was present as the homes manager was on annual leave. Discussions also took place with the registered provider, the activities co-ordinator, several nurses, care staff and ancillary staff on duty. A number of residents were also spoken to on both days. Records looked at included medication, care planning documentation, health and safety information and staff files. A tour of the premises also took place. The Quality Assurance manager completed the Commissions Annual Quality Assurance Assessment (AQAA), which is a self-assessment survey, and the self-assessment has been used to support some of the judgements made concerning the service. On the first day of the inspection surveys were left at the home to be handed out to relatives, residents, staff and professionals. At the time of writing this report 21 questionnaires had been received from residents, with the exception of two residents who had been supported by the activity co-ordinator to complete the form. Seven surveys were received from staff, and one from a visiting professional. No surveys were received from relatives and no relatives were seen during the inspection visit. Questionnaires received, raised no significant concerns, with the majority of people being satisfied with the care and support received. Comments from the questionnaires have been reflected in the main body of the report. Residents were spoken to during the inspection visit and were largely positive about life at the home. However, communication with many of the residents proved difficult for the inspectors due primarily to the level of the peoples dementia or due to the level of their mental health. Residents were observed to move freely around the home and those seen appeared relaxed and at home. Appropriate interaction was observed between residents and staff with a lot of warmth and empathy being evident. What the service does well: The standard of meals remains good at this home. The majority of residents spoken to were complimentary about the food. Cultural and dietary needs are met. The quality assurance manager continues to have a good knowledge of residents’ dietary needs, likes and dislikes. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 6 Staff reported that the morale is good and that they worked well as a team to meet residents needs. The Registered Manager is approachable and she is liked and respected by residents. The home has a comfortable and relaxed atmosphere. The home has a full–time activities co-ordinator who facilitates a variety of daily activity sessions and events for residents. A well equipped recreation room is available for use by residents, although activities also take place in the various lounges. What has improved since the last inspection? What they could do better: The home needs to improve the recording of actions taken following audits of medication and to continue to monitor the administration of medication. The home must obtain a copy of the new London Borough of Wandsworth Adult Protection Procedures. The home needs to ensure that it informs the Commission for Social Care Inspection of any events affecting the health and well being of the residents. Staff training to help meet the health care needs of residents needs to take place. This must include wound care and diabetes care. No staff should start working in the home without a POVA first check being carried out Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a Statement of Purpose, which sets out the aims and objectives of the home, and includes a service user guide, which provides basic information about the service and the types of care the home offers. An assessment procedure is in place and staff from the home carry out their own assessment visits to ensure that the home can meet the person’s assessed needs. EVIDENCE: Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 10 The Statement of Purpose and Service User Guide is in place, which contains information about the home’s aims and objectives, service provision and terms and conditions. It also provides information on activities and health and social links available for residents. The manager reported that all residents are offered a copy of the document and a form has been devised to register whether they want an individual copy. If they do not want a copy of the guide, it is held in their care plan, which residents have access to. Copies of the service user guides were seen on the care plans examined. Contracts between the home and the placing authorities were seen and are kept in the proprietor’s office. Care manager assessments, as well as the home’s managers assessment were seen in all the files examined. The home’s managers assessment focused on activities of daily living model e.g. breathing, body temperature, elimination, washing and dressing, mobility, social and emotional, sexuality and sleeping. A mental health assessment was also in place where residents diagnosed with a mental disorder. Assessments were seen to have been updated by care managers or their CPN. Several residents spoken to were aware of who their care worker was and their role in the home. Intermediate care is not provided in this home. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9, & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are in place and are being reviewed regularly. There is evidence of multi-disciplinary working with healthcare professionals, however, there is a lack of awareness by staff on some health issues that could potentially be viewed as placing residents at risk. The medication system in place must be monitored more closely to ensure that the system for compliance with the administration, safekeeping and disposal of drugs is clear to staff who have responsibility for administering medication. EVIDENCE: New Care plans have been introduced, which are more comprehensive and detail more information regarding the resident’s care needs. Five care plans Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 12 were looked at and were individualised and easier to follow than previously. Plans also contained clear, personal information on the resident’s next of kin, GP and their medication. Care plans were seen to be reviewed monthly by staff. Three Care plans were signed by the resident, the other two the manager said were not able to sign their plans. This should be recorded on the plan. A daily living profile was also seen, as well as background information regarding the person’s earlier life, which provides a pen picture of the resident, which is helpful. A mental status assessment was also seen to be in place for residents who suffer with a mental disorder and CPA reviews were seen on three of the files examined. One CPN stated in their survey, “staff are always happy to have joint meetings to discuss patients progress”, “ staff will always inform me if any information needs to be passed on”. However one care plan looked at states that “resident is an insulin dependant diabetic and states ‘monitor blood sugar glucose regularly’ .The care plan does not state what is meant by this, or how often blood glucose should be measured. The local hospital stated that the resident had not attended the hospital appointment with the relevant information. This was discussed with the managers who stated that the home would not necessary send information if it was not requested by the hospital. Where residents are attending a diabetes clinic details of there blood glucose readings and medication chart should be sent with them. The manager must seek advice from hospitals whether this should happen and the outcome recorded. The CSCI Pharmacist inspector assessed medication management as part of the main inspection. The quality of this area outcome is poor. A significant number of issues were found, some of which would have adversely affected the health of some residents. A list of issues was provided to the Manager, as some required immediate action and 4 immediate requirements were left. Examples include prescribed medicines out of stock, some doses missed as staff could not find medication, medication not given according to the prescribers instructions, missing signatures on administration records so it could not be determined whether a dose had been given, depot injections missed and no explanation given on the administration record, and incorrect storage of medicines including a controlled drug. The CSCI Pharmacist returned to carry out a follow-up three weeks later, and some of the issues had been resolved. Although the home has taken action and the standard has improved, some of these issues have been raised at previous inspections. In 2006, a number of serious issues with medication management were noted which were resolved within a few weeks, however the home has slipped back into poor practise over the last year. This shows that systems for picking up issues e.g. medication audits are not effective and therefore the standard of medication handling has not been maintained at a safe level. Since the inspection, some staff have received refresher medication training, the prescriber and pharmacist have been involved in meetings to help the Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 13 home to improve medication handling and the Manager has been carrying out regular audits to identify and resolve issues found. Nine requirements were made. Some of which were met at the follow up inspection, which are detailed at the end of the report. The home must demonstrate that it can maintain a safe standard. Inspectors found communication with some residents was difficult due to their level dementia or mental disorder. However, those spoken with said that they are treated ok. Comments received include “ its nice here” “staff are friendly and kind”. Staff knock on my door and wait before coming in”. Screens are available in the double rooms for privacy and dignity when personal care is being carried out. None of the residents spoken with said that they did not want to share a room. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 14 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. 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 this 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 and friends. Positive interaction was observed between residents and staff and a varied programme of activities for residents is now in place. EVIDENCE: A full time activities co-ordinator is in post at the home. The home has a separate activities room in the garden, which is well resourced with arts and craft materials, books, newspapers, sewing materials, Television and DVDs. In discussion with the co-ordinator, she was very aware of residents interests having sought their views regarding appropriate activities. Activities are varied as well as individual e.g. there are reminiscence mornings, discussion on local events, current news, as well as art and crafts sessions, some of which is displayed in the recreation room as well as in the home. There are also film evenings and baking sessions, as well as regular local outings to church. Bingo Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 15 was seen to take place in the afternoon on the first day of the inspection, which was staff led. Residents seem to enjoy the activity; positive interaction was seen with the staff team. The co- coordinator spoke of the recent trip to Brighton and of the home’s annual garden party. The co-ordinator stated that she was currently in discussion with the residents in organising a trip out locally to a place of interest. Events in the home is publicised on a notice board, which let’s all residents and relatives know what is happening and when. The quality assurance manager stated that when big events e.g. trip to Brighton take place those residents who choose not to go are made a fuss of in the home. She also stated that the home plans to expand upon the events on offer and they are going to devise an information and welcome pack for new residents. Residents meetings are held monthly, although records examined did not evidence this to be the case. Meeting minutes are logged - this year for January, February and March. Attendance does not look good – 7 residents in Jan, 10 residents in Feb and 12 residents in March. Minutes read more like a list of what residents want or need e.g. In January one resident wants a bath more than once a week!. It states that an arrangement has now been made for her to have a bath everyday. Other responses (e.g. in response to ‘I would like a bus pass’) just state ‘I will discuss with the manager.’ In discussion with the managers, they stated that they are looking at trying to invite relatives to meetings. Residents however, appeared content. Several, when spoken to, said that they “liked the home, the food was very good the staff were kind. One resident said that ‘it’s alright.’ ‘I like playing games like dominoes or draughts’. This resident gets up early, which is their choice and says the food is good and you get a choice. Another said that he was happy and likes to listen to reggae. One resident who goes out on his own spoke of his visits to various churches which he enjoys going to. Several residents said that visitors could come at any time, although few residents spoken to actually received visits from their relatives or any friends. Residents are encouraged to remain in touch by telephone or letters. One resident showed an inspector a birthday card he had received from his sister, as well as two cards from staff. The Annual Quality and Assurance Questionnaires state “that the home encourages residents with capacity to handle their own financial affairs. We also maintain our policy of encouraging all residents to bring any possessions that would make their living area more personal”. This was seen to be the case in two of the rooms seen. Lunch was observed. Residents are given a choice as to where they can have their lunch. The main dining room was appropriately set with tablecloths, napkins and condiments so that residents can help themselves. A jug of squash was also available. Most residents spoke positively of the food and Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 16 those residents in the main dining room interacted well with each other during the meal. Residents in the smaller lounges were seen to be appropriately supported by staff and positive interaction seen, with the exception of one resident, who asked the inspector for a drink and when the inspector asked the staff, she was informed that drinks are given after the meal, as it will discourage residents to eat if given a drink with their meal. This was discussed with the Quality assurance manager who said that this is not current practice and that she would discuss this issue with staff. Prior to the meal being served, residents are asked what they would like and the meal is then plated and brought to them. A record is kept of this. Many positive comments were received regarding the food. Inspectors were informed that teatime has now moved from 1600 to 1630 in response to issues raised by residents. Also changes have been made to the breakfast routine. A breakfast trolley goes around and contains an assortment of items such as croissants, toast, breakfast bars and individual jams to give more choice. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place to protect residents however, procedures are not always followed which potentially could place residents at risk. EVIDENCE: The managers reported that the home had a Safeguarding Awareness day on the Friday before the inspection visit. They said that abuse is discussed in staff meetings and on an individual basis with staff. Staff are also regularly sent on the Local Authorities Safeguarding of Vulnerable adults training. However, evidence seen in the home, identified that the home had failed to act appropriately in notifying the Commission and social services when abuse was identified. The matter had been addressed in –house, which was totally inappropriate and identify that training and the home’s policy is not being followed, which place residents at risk. The home must report any incidents of abuse to social services for them to investigate, as they are the lead agency. Advice given must be followed. This issue was discussed with the proprietor as well as the two managers. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 18 The home maintains a bruise book, which the purpose of is unclear. The home was advised to use body maps and skin assessments re: bruising and to notify social services. The Commission or the home had not received any formal complaints since the last inspection. The majority of questionnaires received stated that residents knew who to complain to if they were not happy in the home. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides residents with a comfortable place to live. The standard of maintenance of the premises is satisfactory, although several bedrooms seen require decoration and new furnishings, which inspectors were informed was being addressed through the on going refurbishment programme. The home was clean and hygienic on both days of the inspection. 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 days of Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 20 inspection. Likewise, the back garden was equally attractive with floral displays. The quality assurance manager said that the rolling programme of maintenance and refurbishment of rooms is on going. There are 18 shared bedrooms and a screen on wheels is available in each room to provide a degree of privacy, particularly when personal care is being carried out. Bedrooms have linoleum flooring, single beds, wardrobe, chest of drawers and a wash hand basin. Some bedrooms seen included pictures and had been personalised by the individual or their relatives, while other bedrooms were very bare. In discussion with staff, they stated that due to some residents mental health, they do not want their room personalised. Others cannot afford to do a lot, due to a lack of funds. Few rooms seem were personalised, however, residents spoken to all said that they were happy with their rooms and had no complaints. Resident’s names are written on a nameplate on the door. In one of the double rooms seen, one of the residents had recently died, yet his name was still on the door. This should not occur and steps should be taken to delete names as soon as possible following death. The conservatory area has been identified as the designated smoking area, as well as the garden, which is quite large and well maintained. A large sign on the conservatory door identifies the area for smokers. A laundry area and hairdressing area is available. The laundry person confirmed that all appliances work. The home was clean, hygienic and free from offensive odours on the day of the inspection. One member of cleaning staff is responsible for each floor of the home. Several residents commented that the home is well kept and is clean. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 21 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. 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 this service. Sufficient numbers of staff are employed, which is kept under review depending on residents assessed needs. Recruitment practices must ensure that appropriate checks are carried out prior to staff being employed. Failure to do this could place residents at risk. Staff training must continue to improve with emphasis on training for nurses in areas such as wound management and diabetes care. EVIDENCE: The managers reported that adequate staff are employed in the home and staffing levels are kept under review depending on the needs of the residents. At the time of the inspection, the staff team per day shift consisted of 3 nursing staff and nine care staff, as well as two managers, the activities coordinator, and ancillary staff. At night there are 2 nursing staff and 5 care staff. Managers reported that sufficient staff is employed. Staff in their questionnaires did not indicate that more staff were needed. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 22 Managers and staff spoke positively of the training offered. However, a lot of the training offered is in–house with nurses expected to find and attend courses for their professional development. Pin numbers are checked by office staff and seen to be in place for the nurses files looked at. However, the managers in the home have a duty of care to its residents to ensure that nurses are up to date in current practices e.g. wound care and diabetes care, which was seen not to be the case and potentially could place the resident at risk. Inspectors were informed by the managers that they both attend two monthly forum’s held for local care homes run by Wandsworth Social Services. They said it is a useful way to remain updated and that the speakers cover topics such as nutrition and activities. Recruitment practices must improve, as five staff had been recruited without the POVA first check having been carried out. This was rectified within days, but the home must ensure that staff who are appointed with a current CRB check must also have a POVA first check carried out prior to starting work in the home. Other required checks were seen in place. Staff are issued with a contract and terms and conditions. Supervision was seen to be taking place as was staff meetings. Staff files examined evidenced that mandatory training was being carried out, as well as training in mental health awareness and dementia care. In house induction was usually completed within 48 hours. The home is registered with Skills for Care but managers stated that the home is behind for new staff, due to the registration process and now aims to complete the Common Induction Standards within three months and the foundation standards within six months. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager continues to provide clear direction and leadership. Staff supervision has improved, ensuring that staff have the support they need to carry out their roles. Health and safety systems are in place to ensure the safety of residents and staff. EVIDENCE: Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 24 The manager is appropriately qualified and experienced to manage the home and has worked there many years. She had a good knowledge of the residents and their needs. Several staff said that she was “approachable and supportive”. One health/social care professional commented, “ staff are always pleasant, polite and willing to share information about the client” The AQAA states that the management team has a very good relationship with the health professionals. The quality assurance manager has worked in various roles in the home for many years and is using that experience to support the management team. Questionnaires had recently been sent out to residents, relatives, as part of the quality assurance system in place. Responses from residents and staff was poor, whereas relatives was good. Inspectors were shown relatives responses, which on the whole were positive regarding the home and support given to residents. The home is still in the process of collating theses comments to produce a report with outcomes/targets for the home. The home must include stakeholders in their quality assurance. The Commission must be notified when residents are admitted to hospital, or of any event in the care home, which adversely affects the well –being or safety of the service user. This was seen not to have occurred, although the manager sent through the written notification of two earlier hospital admissions before the second day of the inspection. There have been no changes since the previous inspection as to how resident’s money is managed in the home. Resident’s monies are held separately and information detailed in the AQAA states that residents are encouraged to control their personal finance so long as they are mentally competent to do so. A programme for supervision is in place, which is being adhered to, with supervision being carried out by manager’s bi-monthly. Both staff and managers reported that this was working well. Health and safety checks were found to be in order. Up-to-date certificates were seen in respect of: gas safety, fire safety, and evidence was seen that fire drills takes place monthly. Electrical installation and portable appliance checks identified as requiring updating on the first day of the inspection were address before the second day. A legionella risk assessment is in place. Hot water temperatures are being checked and none above 43 degrees centigrade. However, on 25/05/07 they were not checked, as ‘it was a bank holiday.’ This is not a good reason. Inspectors were informed that COSHH assessments were due to be updated this month and were in hand. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 3 X X 3 3 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 2 3 3 3 X 2 Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 26 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 2 3 Standard OP8 OP18 OP8 OP9 Regulation 12(1) 18(1)(a) (c) 12(1) 18(1) (c) 13(2) Requirement Timescale for action 30/08/07 4 OP9 13(2) All staff must receive training in wound care and care plans appropriately documented. All staff must receive appropriate 30/08/07 training in diabetes care. Staff must ensure that all 21/07/07 prescribed medicines are available at the home. Immediately – Met at follow up inspection. Staff must ensure that all 21/07/07 prescribed medicines are available at the home. Immediately - Met at follow up inspection. Staff must ensure that controlled 21/07/07 drugs are stored according to the Misuse of Drugs Safe Custody Regulations. Immediately- Met at follow up inspection. The home must ensure that medicines are stored at the correct temperature. Immediately –Met at follow up inspection. DS0000019117.V343103.R02.S.doc 5 OP9 13(2) 6 OP9 13(2) 21/07/07 Rosedene Version 5.2 Page 27 7 OP9 13(2) The home must ensure that risk assessments for residents selfadministering medicines are available, and reviewed regularly. Partly met at follow up inspection on 21st July. New date agreed. 30/09/07 8 OP9 13(2) 9 OP9 13(2) The home must ensure that the 30/08/07 action taken when residents refuse their medication regularly is recorded. Partly met at follow up inspection on 21st July. New date agreed. Staff in the home must ensure 30/08/07 that there is a clear audit trail for all prescribed medicines (date started/stopped/changed) Partly met at follow up inspection on 21st July. New date agreed. The home must ensure that photographs of each resident are available in the MAR Chart folder. Partly met at follow up inspection on 21st July. New date agreed. The home must ensure that all prescribed items are fully labelled with instructions for use, in particular creams/ointments and inhaled products. The home must look at how they can develop the focus of the residents meetings and involve more residents to exercise choice and control in their daily lifes in relation to all their health and social care needs. All staff must be trained in recognising; understanding and DS0000019117.V343103.R02.S.doc 10 OP9 13(2) 30/08/07 11 OP9 13(2) 31/08/08 12 OP14 12(2) (3) 30/08/09 13 OP18 13(4&6) 18(1) c 01/08/07 Rosedene Version 5.2 Page 28 reporting abuse and are aware of the organisations whistle blowing policy. (Timescale of the 01/08/06) A copy of the most up-to-date Wandsworth Protection of Vulnerable Adult Guidelines must be obtained. 14 OP18 13(4) Where residents have sustained bruising these must be fully documented and the appropriate health and social care professionals must be informed. No staff should start working in the home without a POVA first check being carried out. The quality assurance system must include the views of stakeholders. The Registered Person must ensure that the Commission for Social Care Inspection is notified of all events that affect the wellbeing and safety of the service users. (Timescale of 1/07/06 not fully met.) 30/07/07 15 OP29 16 17 OP33 OP33 19(4)(a) (b) Schedule 2 24(3) 37 01/08/07 01/09/07 06/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations Consideration should be given to different ways to label residents bedrooms. Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rosedene DS0000019117.V343103.R02.S.doc Version 5.2 Page 30 - 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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