Inspection on 11/04/06 for Roseland Care Home

This inspection was carried out on 11th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Roseland Care Home 25/02/08

Roseland Care Home 16/07/07

Roseland Care Home 04/12/06

Roseland Care Home 09/11/05

Roseland Care Home 06/07/05

Roseland Care Home 23/02/05

Roseland Care Home 12/08/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Roseland Care Home 57 Draycott Avenue Kenton Middlesex HA3 0BL Lead Inspector Richard Adkin Unannounced Inspection 11th April 2006 09:15 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 Care Home DS0000017443.V287693.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. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Roseland Care Home Address 57 Draycott Avenue Kenton Middlesex HA3 0BL 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 8907 4080 020 8959 1249 Mr Jerome Manuel Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Roseland Care Home is situated in a busy residential road off Kenton Road. It is close to a large supermarket, local shops, tube and bus routes. It is a detached house on two floors. There is one double and eight single bedrooms. There is a large lounge and separate dining area as well as a kitchen, laundry, shower and toilet on the ground floor. There are two single and one double room on the ground floor. Upstairs rooms are all single and there is a bathroom on the first floor. There are no en-suite facilities in the home. There is a chair lift to the first floor. There is a pleasant garden laid mainly to lawn with trees and shrubs at the rear of the property. Garden furniture is provided for service users who like to sit out in the Summer. There is off street parking at the front of the house for three cars. Parking is also available on the main road. At the front of the home there are borders containing shrubs and bushes. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place from 9.15am to 3.45pm midweek. The manager was on duty with one care staff member and the cook was preparing the lunch. Two care staff came on duty in the afternoon and the proprietor kindly made himself available. The Inspector had opportunity to look around the care home to meet residents, two visitors and the GP. All key national minimum standards were inspected on this occasion as well as requirements from the previous inspection and additional visits. There have been three additional visits to the home since the last inspection in 2005 because of concerns about adult protection and complaints about the home. This included a visit by the CSCI Pharmacist. One immediate requirement was made during this inspection. The Inspector would like to thank everyone at the home for their contribution to the inspection. What the service does well: What has improved since the last inspection? What they could do better: There are a significant number of areas that need addressing from this inspection, as well as outstanding requirements from previous visits. The home must to be managed and led by a manager who must be registered with the CSCI. Communication has to be considerably improved whether through having regular team meetings or supervision or through the recording and passing of information which on occasion reflects poor practice. Staffing rotas need to be Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 6 better managed. The Proprietor needs to be more effective in his monitoring and actions taken. The outstanding requirements from the previous inspection concerning the environment must be addressed. For example, replacement of bed linen and towels and replacement beds. Some of the bedrooms remain needing various improvements. Residents need and would like meaningful activity and these must be in place to enhance the quality of their lives. The requirements from the Pharmacist visit on 21st March 2006 must be addressed within the requisite timescales. Policies and procedures must be updated as required. 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. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 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 Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality in this outcome areas is adequate. This judgement has been made using available evidence, including a visit to this service. Further work is required. An integrated policy and procedure needs to be in place to ensure that new residents needs will be assessed and assured that these will be met. EVIDENCE: A long standing requirement that has been outstanding for three previous inspections that has arisen is that the three documents that referred to the referral, assessment and introduction to the home needed to be reviewed and an agreed policy is needed. This has not taken place and remains a requirement that needs to be put in place in order to improve practice at the home. Information looked at on the most recent resident that was admitted to the care home provided adequate information on the needs of that resident. An adequate assessment was on file, though details were minimal. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 The quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. Care plans need reviewing regularly to ensure residents’ needs are met. The health needs of residents must be immediately addressed as they are not being fully met. Concerns raised by the CSCI Pharmacist must be addressed fully. EVIDENCE: A sample of care plans were in place and found to be adequate, but were not being reviewed on a monthly basis. A requirement that arose from an additional visit made the previous month to the care home by the Inspector, was the need to securely store residents’ bottles of spirits and sherry on display in the office. This has now happened, it remains needing to be addressed a risk assessment relating to the units of alcohol consumed that has been agreed with residents and their relatives where appropriate. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 10 A fall risk assessment had been carried out for one resident addressing the health needs around diabetes management of that particular resident. There remains a need for a body map to be put in each resident’s file as previously required as this has not happened yet. The purpose of this body map is for staff to record when they observe any bruising or injuries on residents. An immediate requirement was issued as the Inspector observed one resident with an inflamed bruise and cut that staff on duty were not aware of. It transpired that there was a record of a fall causing the bruising and put in the handover records. The manager must monitor the daily records and night reports each day and take action in the events of falls or other accidents or incidents to residents, which has not been reported or followed up by care staff. The Inspector was concerned that this monitoring had not been carried out as required from previous inspections. The accident was not properly handed over or properly recorded in the accident book or care notes. The GP was contacted and visited promptly during the course of the inspection; the GP prescribed antibiotic cream that was needed. Weighing is taking place monthly for some residents. However, three residents who are more physically disabled are not being weighed monthly. Previously it was required that advice was being sought from the District Nurses to ensure that this monitoring and recording of weight takes place and further advice should be sought to weigh more vulnerable clients.. The requirements arising from the Pharmacy Inspector’s visit on 21st March 2006 and report, must be fully addressed - see Requirements section for full details. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There is little evidence that residents have stimulating activities provided by the home. Residents receive wholesome home cooked food, it is well presented and meets the dietary needs of residents. EVIDENCE: It remains recommended that the manager identifies two members of staff to carry out and plan activities. These staff have now been identified by the Proprietor to plan and lead on activities for the residents. The activities list has now been moved from the office to being displayed in the lounge for visitors and residents to see. However there was no evidence throughout the inspection of residents undertaking meaningful activities. One resident spoke of her wish to do more physical activities. One resident did receive a visit from a hairdresser who is also a family friend who attends to the residents’ hair weekly. The focus in the living room is the television. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 12 The cook serves wholesome food; menus with choices are on show and food eaten by residents is captured and recorded. Positive feedback was received from residents about the quality and quantity of the food. The meal being served at the time of the inspection looked well prepared and presented. Food preferences of residents was noted and menus were on display. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. Processes need to be in place to ensure that residents are fully protected from abuse. EVIDENCE: Protection of Vulnerable Adults guidelines for the London Borough of Brent, or policies of authorities from where residents originated, were not available. As a staff group, the protection of residents from verbal and physical abuse in light of the local authority guidelines, and the home’s own adult protection policy should be looked at. It therefore remains recommended that this takes place as a matter of good practice to ensure that staff are clear about the issues involved in adult protection. Communication was poor (as noted in Standard 7), around an injury that had taken place to one of the residents needing GP attention. Two anonymous complaints have been received by CSCI relating to staffing and medication and environment issues. A separate complaint was received via the London Borough of Brent, which led to follow up action by the London Borough of Brent and CSCI. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 14 The home must ensure that all accidents are reported to Social Services, CSCI and families and relatives. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 15 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, 25, 26 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. Residents would benefit from further improvements to the care home’s environment. EVIDENCE: There were 23 environmental requirements from the previous unannounced inspection (9th November 2005). A number of these requirements have been tackled by the Proprietor. The remainder must be addressed within the stated timescales. A shopping trolley and raised toilet seat in the back garden were visible from the French windows in the dining room. These need to be removed or stored appropriately. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 16 The boiler is securely locked; however there were several black bin liners beside the boiler. The boiler must be kept clear of potentially inflammable materials. The bin liners were promptly removed by the Manager. There was a patch of wall with peeling paper possibly caused by damp in the corridor between the front door and the bathroom which needs rectifying. The kitchen though refurbished satisfactorily remains in need of further decoration to the wood and walls. It was intended to inspect the linen cupboard, but the door was jammed and could only open partially. This needs repair. In room 10 the mattress was very soft with a poor quality bed base. The wheels also present a potential health and safety hazard. The home however, was clean and tidy and free from offensive odours at the time of the inspection. The process had begun of replacing all the resident’s bed linen with matching duvet covers, valances, sheets and pillow cases, but this needs to be completed as in some rooms there were mixtures of fading bed linen. The towels had needed to be replaced and this needs to be addressed. Looking at room by room there were a number of maintenance issues arising. In room 4 the door needed to be repaired or replaced due to damage caused by a wheelchair. The bedroom wall was similarly marked and remains in need of being decorated. In rooms 1 and 6, a window in each of these rooms was made of re-inforced glass (with wire mesh). This was inappropriate for a bedroom and needs to be replaced with clear glass. The Proprietor indicated that this was the case because of fire regulation, there was nothing however, in writing to indicate to the contrary from the Fire Officer. In room 5 the stained carpet need replacing. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 17 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, 30 The quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to the service. Staff need to work reasonable hours and be in sufficient numbers to fully meet the needs of residents at the care home. EVIDENCE: A requirement that had arisen was that the Proprietor needed to ensure that there are sufficient staff on duty to meet the standards relating to food, meals and nutrition and that the home was kept clean and free from dirt and unpleasant odours. There were two members of staff, including the Manager on duty in the morning (along with the cook), and two staff came on in the afternoon. Sufficient staff were around to meet nutritional needs of the residents and to ensure the cleanliness of the home. The Manager however, was stretched in having to provide both care and management of the home, cover was just adequate. Activities for residents were not taking place. The rota was drawn up only for a week cycle and this needs to be monthly to provide a record of shift patterns. One care worker seemed to be working excessive hours (even if they have opted out of the European Directive on Working Hours). The Proprietor must ensure that excessive hours are not worked for the safety of the care worker and the residents. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 18 Sufficient numbers of staff must be on duty to provide effective care to residents. Clarity in respect of the waking/sleeping night staff duties is required and respective job descriptions sent to CSCI. The induction records of staff were not available for inspection as they were held by the Proprietor, but should be made accessible. Furthermore, should the Proprietor or Manager carry out spot night checks, evidence must be provided of findings. There was no evidence of a formal training programme being in place for the home and this needs rectifying. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 19 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, 32, 33, 36, 37, 38 The quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to the service. A registered Manager must be in place in order that responsibilities to the residents and carers in fully discharged. There is no evdence of formal staff supervision or staff meetings. A full monthly auidit of the home needs to be done by the proprietor. Staff need to be vigilant in recording and reporting incidents. EVIDENCE: The Manager of the home will be completing her Registered Managers’ Award (RMA) in June of this year. The home must be managed and led by a registered Manager and it is requirement that there is a registered Manager in place who has space and opportunity to manage the home and to discharge their responsibilities fully. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 20 Supervision was taking place during the course of the inspection. This was the first supervision that had taken place and needs to be established as a pattern. There needs to be sufficient staffing levels when supervision is taking place. No staff meetings are taking place. These need to happen and must be recorded. The Proprietor noted difficulties about getting the staff group together. No signing in book was available for visitors (whether professionals or family members etc.), to record visits to the home. These records are required by regulation to protect residents and support the running of the home. The Proprietor must ensure that he reviews the premises as part of his monthly monitoring visits in order that repairs and other issues can be identified and addressed more quickly. The Inspector was shown a new Quality Control Audit folder that provided a sound framework for undertaking this work. However, there were no entries or sections completed by the home. The home’s policies and procedures manual must be reviewed, updated, indexed and dated. This manual will be continued to be reviewed on each inspection to strive towards policies meeting National Minimum Standards. Care records looked at by the Inspector were either not up to date on individual resident’s files or not recorded. Likewise, the Manager must ensure that staff members are comprehensive and vigilant when recording information in accident and incident records and daily records and that these are acted upon accordingly. Standard 38 was partially inspected and will be looked at further at the next visit, along with Standard 35, safeguarding resident’s financial interests. Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X 1 2 2 STAFFING Standard No Score 27 1 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X X 2 2 2 Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation Requirement Timescale for action 01/06/06 14(1)(a)(c The three documents that ) referred to the referral, assessment and introduction to the home must be reviewed and an agreed policy put in place. (Previous timescales of 30/04/05 and 31/08/05 and 31/1/06 not met) 13(4) Residents care plans must include a risk assessment relating to the units of alcohol consumed, where appropriate. (Previous timescale of 7/4/06 not met) The Manager must monitor the daily records and night reports each day and take action, the events of falls or other accident/incidents to residents which have not been reported or followed up by care staff. These accidents must be properly recorded. (Previous timescale of 16/12/2005 not met) 2. OP7 01/06/06 3. OP7 13(10(b) 11/04/06 Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 23 4. OP7 13(1)(b)1 7 5. 6. OP7 OP8 15(2)(b) 12(1) A body map must be in each resident’s file for staff to record when they observe any bruising/injuries etc. Previous timescale of 19/12/05 not met) Care plans must be reviewed on a monthly basis. Weighing must take place monthly for all residents including the more physically disabled residents. The requirements arising from the Pharmacy Inspector’s visit and report must be fully addressed. Meaningful activities must take place for residents. POVA guidelines for the London Borough of Harrow and relevant local authorities must be available. The linen cupboard door only opens partially and this needs repairing. The shopping trolley and raised toilet seat must be removed from outside the French windows in the dining room. 01/06/06 01/06/06 01/05/06 7. OP9 13(2) 01/06/06 8. 9. OP12 OP18 16(m) 12(1)(2) 01/05/06 01/06/06 10. 11. OP19 OP19 23(2)(b) 23(2)(b)( o) 01/06/06 01/05/06 12. 13. 14. OP19 OP19 OP24 23(2)(b)(c The kitchen though refurbished, ) needs decoration. 23(2)(b) The damp patch of wall between the front door and the toilet needs redecoration. 23(2)(b) Room 10. The mattress is soft (d) with a poor quality bed base. The wheels present a potential health and safety hazard. These remain needing to be replaced. Previous timescale of 31/1/205 not met) 01/06/06 01/06/06 01/06/06 Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 24 15. OP24 16(2)(c) 23 (2)(b)(d) Room 4. The door must be 01/06/06 repaired/replaced due to damage caused by the resident’s wheelchair being pushed against it. The bedroom wall remains similarly marked by the wheelchair and must be redecorated. (Previous timescale of 31/12/05 not met) The process of replacing all the resident’s bed linen with matching duvet covers, valances, sheets and pillow cases, along with towels must be completed. (Previous timescale not met) Room 3. The replacement flooring is damaged and needs replacing. Evidence is needed on file that consultation has taken place concerning the flooring with the resident’s family. The resident is unable to make informed choice. (Previous timescale of 31/12/05 not met) Rooms 1 and 6. One window in each of these rooms is made of reinforced glass (with wire mesh) and is inappropriate for a bedroom and must be replaced with clear glass unless the Fire Officer indicates to the contrary. Room 5. The stained carpet must be replaced. 01/06/06 16. OP24 16(2)(c) 23 (2)(b)(d) 17. OP24 16(2)(c) 23(2)(b)( d) 01/06/06 18. OP24 16(2)(c) 01/06/06 19. 20. 21. OP24 OP25 OP27 1692)(c) 13(4)(c) 10(1) 13(4) 13(1)a 01/06/06 The boiler must be kept clear of 11/04/06 potentially inflammable materials Clarity in respect of the waking/sleeping night staff duties is required. Job descriptions for waking DS0000017443.V287693.R01.S.doc 01/06/06 Roseland Care Home Version 5.1 Page 25 night/sleeping in staff must be sent to CSCI. Should the Proprietor/Manager carry out spot night checks, evidence must be provided of findings. (Previous timescale of 30/4/06 not met) 22. OP27 18 The Proprietor must ensure that care staff do not work excessive hours (even if they have opted out of the European Directive on Working Hours), in order that they are working effectively. A formal training programme for the home must be in place. The Manager of the home must be interviewed and registered with CSCI at the earliest opportunity. Staff meetings must take place regularly and must be recorded. The Proprietor must ensure that he reviews the premises as part of his monthly monitoring visits so that repairs etc. can be identified more quickly. (Previous timescale of 30/11/05 not met) 11/04/06 23. 24. OP30 OP31 18 8 01/06/06 01/06/06 25. 26. OP32 OP33 21(1) 26 01/05/06 01/05/06 27. OP33 24 28. OP33 24 29. OP33 18(2) The Quality Control Audit in 01/06/06 place needs to be put into operation and have entries in the folder. The home’s policies and 01/06/06 procedures manual must be reviewed, updated, indexed and dated. This manual will be reviewed on each inspection to ensure policies meet National Minimum Standards. (Previous timescale of 31/3/06 not met) Staff supervision must take place 11/04/06 DS0000017443.V287693.R01.S.doc Version 5.1 Page 26 Roseland Care Home at least six times a year with records kept. (Previous timescale of 7/4/06 not met)7/4/06 not met) 30. OP37 17(2) Sch 4 17 A visitors’ book must be in place and in use to record the names of all visitors to the care home. Care records must be up to date and recorded on each individual resident’s file. The Manager must ensure that staff are comprehensive and vigilant when recording information in accident and incident records and daily records and appropriate action is taken. 01/06/06 31. OP37 11/04/06 32. OP38 17(1)(3) 11/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 1. 2. Refer to Standard OP8 OP12 OP18 Good Practice Recommendations Further advice should be sought from District Nurses regarding weighing vulnerable residents. It is recommended that the manager identifies two regular members of staff to plan and lead on activities for the residents. It remains recommended that the manager meets with the staff group to go through the home’s adult protection policy as a matter of good practice to ensure that they are clear about the issues involved. The staff rota should cover a one month period. The induction records of staff should be available and accessible for inspection. 3. 4. OP27 OP30 Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Roseland Care Home DS0000017443.V287693.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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