Inspection on 30/04/07 for Roseland

This inspection was carried out on 30th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Roseland 25/02/08

Roseland 05/01/06

Roseland 14/07/05

Roseland 10/01/05

Roseland 29/07/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Roseland Roseland Garratts Lane Banstead Surrey SM7 2EB Lead Inspector Sandra Holland Unannounced Inspection 30th April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Roseland DS0000013772.V333219.R01.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. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roseland Address Roseland Garratts Lane Banstead Surrey SM7 2EB 01737 355022 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) Banstead, Carshalton & District Housing Society Limited Mrs Sandra Parr Care Home 39 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (39), of places Physical disability over 65 years of age (5) Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The age/age range of the persons to be accommodated will be: OVER 65 YEARS Of the older people accommodated up to five (5) may have a physical disability. Of the older people accommodated up to three (3) may be people who suffer from dementia These management arrangements must be reviewed should there be any change to the registered persons - Mrs Parr as Registered Manager or Mr Stevens as the Responsible Individual. 5th January 2006 Date of last inspection Brief Description of the Service: Roseland’s was purpose built in the 1950s and now accommodates up to 39 older people. Up to five residents may have a physical disability and up to three residents may have dementia. A sister home under the same management is situated nearby. The home is sited in its own grounds with well-maintained, level gardens which are accessible to residents. Limited car-parking facilities are available to the front of the home. The home has been modernised and developed and is currently extending the main lounge, adding a conservatory and extending a number of bedrooms to provide en-suite facilities. A passenger lift and stairs enable all residents to access both floors of the home. The fees at this home range from £ 415.00 to £ 590.00. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulatory Inspector carried out the inspection over eight hours. Mrs Sandy Parr, Registered Manager and Mr Mike Stevens, Registered Responsible Individual were both present representing the service. A tour of the premises was carried out and a number of records and documents were sampled, including resident care plans, medication administration records (MAR) and staff files. Seventeen residents and seven members of staff were spoken with. A pre-inspection questionnaire was supplied to the home and this was completed and returned. Information from the questionnaire will be referred to in this report. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents, staff and management for their time, hospitality and assistance. What the service does well: Residents are well cared for and had a high standard of personal presentation. A range of social and recreational activities are available to residents, both in and out of the home. The home provides a comfortable place to live and is very clean and freshly aired. Residents have been encouraged to make their rooms personal with their own belongings. The facilities in the home have been, and continue to be improved, for the benefit of residents. The lounge is being extended and a conservatory room added. A number of bedrooms have already been extended to provide ensuite toilets and washbasins, and more are currently being extended. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 6 Residents are supported and cared for by a stable team of staff, many of whom have worked at the home for a number of years. Staff were cheerful open and friendly. 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. The summary of this inspection report can be made available in other formats on request. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The needs of most residents are assessed before they are admitted to the home. EVIDENCE: The files of a number of residents were seen, including three residents who had been admitted during the past year. The needs of two of these residents had been assessed before they moved into the home and copies of the assessment were seen. The assessment for the third resident was not available, so it was not known if an assessment had been carried out, by whom or when. Residents spoken with confirmed that they or their representatives had visited the home before they were admitted, to ensure that it would suit them and meet their needs. The manager advised that prospective residents are encouraged to have a short stay at the home, to enable them to meet other residents and staff and to enable staff to more fully assess their needs. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 9 The manager stated that a number of residents are supported financially by a local authority and where this is the case, residents have been assessed under the care management process. A copy of the care management assessment for one resident had been obtained and was seen. Intermediate care is not provided at the home the manager stated. A requirement has been made regarding Standard 3. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Plans of the care and support needs of residents have been drawn up to guide staff and some, but not all risks to residents have been assessed. Residents healthcare needs are well met, but the standards of the administration of medication must be improved to safeguard residents. EVIDENCE: As stated previously, the files of a number of residents were sampled and these included their plan of care. These linked directly to the pre-admission assessment form used, and had been drawn up to guide staff to the care and support needed by each resident. It was noted that most of the care plans seen had been recently reviewed and some areas had been updated, but it was clear that care plans had not been reviewed on a monthly basis as recommended by the National Minimum Standards (NMS) for Care Homes for Older People. As the care plans had not been reviewed, they did not accurately reflect the residents’ current needs. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 11 For one resident there was no record of their care plan being reviewed since they were admitted almost a year ago. For another resident whose needs had changed and increased considerably, the care plan did not fully record the changes. Daily notes are written to maintain a record of the assistance and support residents’ require. It was noted that these were not written from the resident’s point of view, but were very care and task based. Few assessments of risks to residents have been formally carried out or recorded. A small number of residents administer their own medication, but the risks associated with this have not been recorded. The manager stated that she informally assessed these residents on admission to ensure they would be safe to manage their own medications. Other risks to residents, including those associated with mobility, falls or dementia had not been assessed, although the risks had been noted in the care plans and some recorded measures to minimise the risks, such as the use of mobility aids. From the information and records seen, it was clear that a number of healthcare professionals are involved in the support of residents and that residents’ healthcare needs are well met. These include a general practitioner (GP), district nurses, continence nurse, optician and chiropodist. It was noted from residents’ care plans, that staff in the home have taken and recorded residents’ blood pressure, but it is not clear if staff have received training in this. This should not be undertaken by untrained people as residents may be put at risk if the results are not properly understood. The manager stated that medication is supplied to the home by a local pharmacy. A number of medications are supplied in “blister packs” which contain varying numbers of medications, and other medications are supplied in original packaging. Each blister pack is usually supplied with a list to state which medications are included, the administration instructions and a description of the medications. It was observed that a blister pack containing medication for one resident had no label or list attached, so staff would have no way of knowing what medication they were administering. A number of other shortfalls were also noted in the standard of medication administration. As medication had been received into the home but had not been recorded, it was not possible to follow an audit trail. Other medications had handwritten instructions to stop the medication or amend the dose, but it was not clear who had authorised these changes or how staff would know which individual medication in the blister pack should not be administered. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 12 Handwritten entries onto the medication administration record (MAR) charts, had not been signed, or checked and countersigned by a second member of suitably trained staff. Staff were observed administering medication after the lunch-time meal and it was noted that a number of residents were left with their medication, which had been dispensed into small, named, lidded pots. Because of the increased risk of errors, it is not good practice to administer medication other than from the original packaging or directly from a blister pack. As the medication was left with residents, it would not be possible for staff to accurately record that the medication had been administered, as they had not witnessed the resident taking it. Staff were observed to speak to residents in an informal, but appropriate manner and residents commented positively on the friendliness of staff. Staff were seen to offer residents choices and to promote their privacy, knocking on bedroom and bathroom doors and waiting for a reply, before entering. An immediate requirement has been made regarding Standard 9 and requirements have been made regarding Standard 7. A recommendation has been made regarding Standard 8. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of activities and are supported to maintain contact with families and friends. A well-balanced diet is provided. EVIDENCE: A weekly activities programme is displayed in the corridor outside the dining room to advise residents of activities planned. These were seen to include quizzes, poetry sessions, bowls, bingo, handicrafts and pampering sessions. A list of the dates of church services held in the home was also seen, and the manager advised that a communion service is held every month. A small number of residents, including some from the sister home nearby, were taking part in a painting session supported by a volunteer, during the morning of the inspection. An enclosed loggia room which opens from the main lounge is made available for painting and craft sessions. It was positive to observe staff sitting chatting with residents or assisting residents with card and board games in the lounge. Other residents were reading their daily newspapers and another small group of residents were sitting in the smaller lounge watching television. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 14 Some residents prefer to spend their time in their rooms and this choice is respected. Many residents have their own televisions in their rooms and others have music facilities. To support residents to keep in touch with their families and friends, a post box is positioned in the hall so that residents can post their own letters and a number of residents have telephones in their rooms. It was clear that visitors are welcomed in the home and residents spoke of their families and friends coming to see them. Records seen also indicated that residents went out to attend local social activities. A three week menu was supplied with the pre-inspection questionnaire and from this it is clear that a well balanced diet is offered. A copy of the weekly menu is also displayed on the notice board in the hall to enable residents to know what meals are available. Residents were very aware that they had a choice of meals and advised that staff ask them each day for their choice of the next day’s meal. The majority of residents stated that they enjoyed their meals and most were seen to thoroughly enjoy the lunch-time meal on the day of inspection. It was positive to note that although the chef was unexpectedly absent on the day of inspection, the management and staff worked effectively together to provide the lunch, with minimal disruption. A slight amendment had to be made to the hot meal offered, but residents were still able to make a choice. The dining room has been extended during the past year to create more space and easier access for residents. Tables were attractively laid with tablecloths, napkins, water jugs and glasses. New china crockery has recently been obtained and new tablecloths have been ordered, the manager advised. To ensure that nutritional needs of residents are met, the manager and senior staff have undertaken training in the use of a Malnutrition Universal Screening Tool (MUST). This enables staff to assess the nutrition needs of residents and includes weighing residents on a monthly basis. The manager stated that the home’s menus have been supplied to the dietician involved, in order that the nutritional content can be reviewed. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Few complaints are received, but those received are appropriately managed. Staff are aware of their responsibilities in the safeguarding of residents. EVIDENCE: From information supplied in the pre-inspection questionnaire, it was noted that only one complaint had been recorded during the last year. The manager was able to advise of the issue involved and how this had been resolved. The manager stated that wherever possible, any complaint made verbally would be responded to immediately by the person in charge, to prevent the need for further action. Numbered, individual complaint forms are available for use if required. It was positive to note that the home receives many letters of compliment and six that had been received since January 2007 were seen. These complimented the home on the standard of care received and the friendly support of staff. From speaking to residents it was clear that they felt able to approach staff or the manager with any complaints or concerns. The manager and staff were observed to interact with residents in an informal and friendly manner, whilst maintaining respect and dignity. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 16 Staff spoken to stated that they have received training in the prevention of abuse and advised that they would report any concerns or suspicions about the abuse of residents, to the manager or person in charge. In the event of an allegation of abuse, the home would follow the Surrey MultiAgency Procedure for Safeguarding Adults (formerly known as the protection of Vulnerable Adults), the manager stated. An up to date copy of the procedure is held in the home for staff to refer to if needed. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a comfortable place in which to live and is being improved and extended for the benefit of residents. The home was cheerful, clean and appeared hygienic. EVIDENCE: The home was purpose built as a residential home in the 1950’s and has been extended and improved in recent years to ensure that it provides the standard of accommodation which residents expect and require. Building work is currently being carried out to extend the lounge and kitchen, to create a conservatory room and to create en-suite facilities to a number of resident bedrooms. Improvements are also being made to bathrooms, and an additional resident bedroom and a treatment room are being created. The treatment room will be used by visiting district nurses and doctors. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 18 Overall the home was attractively decorated in a range of colours, with coordinating soft furnishings and is furnished to meet the needs of residents. There are a number of sitting areas around the home, providing residents with a choice. In addition to the spacious lounge, there is a smaller television lounge, a loggia, and seats are available in the entrance hall and on the first floor landing. Residents were seen enjoying all of these areas. Residents said they had been able to bring their own belongings into the home to make their rooms more personal. These included televisions, lamps, pictures, photos, ornaments and smaller items of furniture. A large, enclosed and level garden was accessible from a number of areas of the home, including a ramp which provides wheelchair access from the dining room. The garden was very well maintained and was stocked with trees, shrubs and seasonal plants and flowers, making a pleasant outlook for many resident bedrooms. All areas of the home were very clean, tidy and appeared hygienic. Handwashing facilities with liquid soap and fabric towels are provided in appropriate places. The use of fabric towels increases the risks of the spread of infection and these must be replaced with paper towels. Staff were also observed to use personal protective equipment, including aprons and gloves, to prevent the spread of infection. The laundry is well equipped with the appropriate facilities, with machines with the required settings and is staffed by an allocated member of laundry staff. A requirement has been made regarding Standard 26. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A stable team of staff of staff are employed to meet the needs of residents. EVIDENCE: From information supplied, it was clear that a full team of staff are employed to meet the needs of residents. These include care staff, housekeeping staff, kitchen staff and an administrator. It was positive to note that many of the staff have worked at the home for a number of years, providing continuity and consistency of care for the residents. Staff spoken with were cheerful, open and understanding of residents’ needs. The information provided also confirmed that only two of the care staff have achieved National Vocational Qualifications (NVQ), to level 2 or higher, which is well below the recommended 50 of staff trained to this level. The manager stated that nine members of care staff have recently been registered to undertake an NVQ and have carried out their induction for this. The recruitment files of a number of staff were randomly sampled. The majority of recruitment documents had been obtained, although it was noted that only one reference had been obtained for each of two staff. Other recruitment checks, including Criminal Record Bureau (CRB) disclosures had been obtained, before staff had started to work at the home. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 20 The management team stated that the same recruitment checks, including references and CRB disclosures, are carried out and obtained for volunteers who help in the home. Information provided in the pre-inspection questionnaire indicated that staff have undertaken training required by law including first aid, moving and handling and the safe handling of medicines. Other training has also been undertaken to develop staff knowledge and skills, including continence, palliative care, depression in the elderly and the MUST malnutrition programme. There is cultural and racial diversity amongst the staff team although the resident group is predominantly British. The majority of staff are female which is reflected in the resident group. A requirement has been made regarding Standard 29. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a person who is fit to be in charge and residents’ financial interests are protected by the home’s policies and procedures. The health and safety of residents is promoted. EVIDENCE: The manager stated that she was previously the manager of the sister home for ten years and has now been the registered manager for both homes for three years. The manager stated that she has completed the NVQ Registered Managers Award during the last year and is an NVQ assessor. The manager is supported by Mr Michael Stevens who is the registered Responsible Individual for the Banstead, Carshalton and District Housing Society, which runs both the homes. Mr Stevens carries out the role of Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 22 administrator in both home and supports the business aspects of running the home. A head of care oversees the day to day care of residents and provides further support to the manager. As noted previously, requirements have been made regarding the standards of pre-admission assessment, residents’ care plans, risk assessments, the administration of medication and staff recruitment. These would indicate that the home needs to be managed in a more robust manner. The administrator advised that monies are held for safekeeping for a number of residents. To safeguard residents’ finances, only administrative or senior staff have access to these and two signatures are recorded for each transaction. Residents are also provided with a lockable facility in their bedrooms, in which to store any valuables. A quality survey was supplied to residents in the summer of 2006, the manager stated, to obtain their views on the standard of the service provided. The survey covered accommodation, care, food and activities and a summary of the outcomes was provided at the inspection. It was noted that almost half of the residents responded and 89 were satisfied with the accommodation, 67 of residents were satisfied with the care they received, 33 expressed satisfaction with food and 61 made no suggestions regarding activities. The survey summary did not state what action would be taken in regard to the results, but the manager did state that residents’ views would be taken into account as the improvements to the home are made. During the tour of the home, no hazards to the health or safety of residents were observed. From information supplied, it is clear that the required maintenance and checks on systems and equipment in the home, are carried out to the required frequency, to promote the health, safety and welfare of those who live and work at the home. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The needs of prospective residents must be assessed before they are admitted to the home and a copy of the assessment must be kept in the home. Each residents’ care plan must be regularly reviewed and revised to ensure it accurately reflects their current needs. Any risks to the health, safety or welfare of residents must be assessed and so far as possible eliminated. The receipt of all medication into the home must be recorded and it must be possible to follow an audit trail. A documented risk assessment must be produced for all residents who undertake to selfadminister their own medication. All medication must be labelled with a dispensing label indicating to whom the medication is to be administered and at what dosage and frequency. All medication must be administered directly from the DS0000013772.V333219.R01.S.doc Timescale for action 30/04/07 2 OP7 15 28/05/07 3 OP7 13 (4) 28/05/07 4 OP9 13 (2) 30/04/07 5 OP9 13 (2) 28/05/07 6 OP9 13 (2) 30/04/07 7 OP9 13 (2) 30/04/07 Roseland Version 5.2 Page 25 8 OP9 17(1)(a) 9 OP26 13 (3) 10 OP29 19 & Schedule 2 12 11 OP31 original labelled container to the resident and not placed into any secondary container. Staff must observe residents taking medication that has been administered to enable an accurate record of medication administration to be maintained. Paper towels must be supplied and used in the home to prevent infection and the spread of infection. Persons must not be employed to work in the home unless and until all the information and documents specified in Schedule 2 have been obtained. The registered persons must ensure that the home is conducted in a manner that promotes and makes proper provision for the health and welfare of residents. 30/04/07 20/07/07 30/04/07 30/04/07 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 2 Refer to Standard OP8 OP9 Good Practice Recommendations It is recommended that only trained healthcare staff undertake the measuring and recording of residents’ blood pressure. It is recommended that handwritten entries on MAR charts are signed by the person making the entry and checked and countersigned by a second member of suitably trained staff. Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Roseland DS0000013772.V333219.R01.S.doc Version 5.2 Page 27 - 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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