Inspection on 04/12/06 for Roseland Care Home

This inspection was carried out on 4th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Roseland Care Home 25/02/08

Roseland Care Home 16/07/07

Roseland Care Home 11/04/06

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 Key Announced Inspection 4th December 2006 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 Care Home DS0000017443.V316304.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 Care Home DS0000017443.V316304.R01.S.doc Version 5.2 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 Coral Lavinia Lake Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 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, and 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. Fees are £370.00 per week, respite £380.00 per week. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced key inspection of the home took place on 11/4/06. A number of major shortfalls were identified from that inspection and the proprietor was required to register the new manager within a given timescale. He was also required to meet the requirements from that and previous inspections within the stated timescale. As part of the monitoring process the inspector carried out three additional visits on 3/7/06, 1/8/06 and 2/10/06 to follow up on a number of recommendations and requirements that needed addressing. The second key announced inspection took place on two weekday mornings in December. The Inspector received seven comment cards from relatives, residents and professionals prior to the inspection. The Inspector had opportunity over the two visits to meet staff, residents, three relatives and the Manager who made herself available throughout. The registered provider was not available. The Inspector would like to thank everyone for their contribution to the inspection. What the service does well: What has improved since the last inspection? What they could do better: A long-standing requirement is that weighing must take place monthly for all residents, including the more physically disabled clients. A process for recording potential and actual Protection of Vulnerable Adults incidents needs to be in place. A mattress that has been identified as being of unacceptable Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 6 softness has yet to be replaced after almost two years. Th efront door needs to be revarnished and the lounge carpet replaced Some recruitment practices need to be tightened up such as an up to date CRB check was missing from one employee’s personnel records and a second reference was missing from two personnel records. Current up to date electrical testing and testing of portable appliances for the care home must happen. A variation order needs to be applied for as several admissions had taken place for residents under 65 with early onset dementia. The home is currently registered for older people only. 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 Care Home DS0000017443.V316304.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 Care Home DS0000017443.V316304.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are not admitted to the home until a full needs assessment has been undertaken and the home is confident that they can meet their needs. EVIDENCE: Considerable work and thought has been given by the Manager in the development of an ‘Admission Sheet’. The Inspector looked at a copy of this admission form during the course of the inspection. The sheet is a form that is user friendly with direct questions and desired outcomes. This captures a range of key areas of daily living, e.g. diet and nutrition, mobility, self-care, including care of teeth. The Inspector looked at the files of several recent admissions. The admissions forms were fully completed with relevant information and guidance. Needs are assessed prior to admission; the Manager discussed a referral where admission Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 9 did not take place as the care home could not meet the needs of the service user who had been referred. Statements of terms and conditions are provided to residents and their relatives. Roseland Care Home DS0000017443.V316304.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, 10, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users now have comprehensive care plans in place, which reflect their needs. The healthcare needs of residents are managed by visits by local health professionals. The home has policies and procedures that inform staff how to meet the residents care needs. Service users are treated with dignity and have privacy in their own rooms. EVIDENCE: The first main area that the current Manager tackled when she arrived was the poor quality of the care plans. A number of requirements had arisen about the quality of care plans previously. The improvements merit detailing given the significant improvements that have taken place over past few months in raising standards. The care plan has prompts regarding assistance required and level of risk. Areas covered include mobility, self care, equipment used, Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 11 continence, communication, sight, hearing, health, medication, diet, cultural and spiritual needs, interests etc. Efforts are now being made to consistently meet the healthcare needs of residents. All the residents were seen by a visiting chiropodist on 2/12/06, particular attention being given to those residents with diabetes. On 7/11/06 a community optician gave all the residents eye tests; one resident was diagnosed with potential diabetes as result. There has been an outstanding requirement for residents to be weighed monthly; in particular the more physically disabled residents. The proprietor is in the process of ordering a wheelchair-weighing device to meet this requirement. The requiremt will remain in place until completed. The Manager has devised a form to record residents weight. Positive feedback forms were received from the GP. Medication records were checked and initials of those giving medication are crosschecked with the name of the staff member. Ongoing medication training is in place. Three members of staff had training in April 2006 and one staff member in July 2006. This is an external course. Policies and procedures for handling dying and death are in place and were looked at by the Inspector. The Manager sends a sensitive letter to relatives of residents and discussion with residents takes place to establish in the event of death, key information including religion, burial or cremation preference. One resident had details of authorisation for donation of body for anatomical examination along with instructions and background information. One bedroom is shared. One resident spoken to in his room enjoyed seeing his daughter there in privacy. His daughter also appreciated this. Progress has been made on the labelling of clothes and preventing them being lost. The matter was discussed at a staff meeting and the Manager has made it part of the key workers role to take responsibility for marking and tracking the resident’s clothing. Positive comments were received by residents, relatives, GP and district nurses about the care received. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 12 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. There has been significant improvement in the provision of activities for residents. The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. There are examples of visits from members of the community such as the church. Food is appetising. EVIDENCE: On the occasion of the first inspection visit communion was taking place for seven people. Bingo took place later in the morning along with a sing along and some festive music being played. The pattern of the television being left on as part of the background noise has now changed. The inspector had noted progress on developing activities for residents during the additional visits to the home over the past few months. On both visits nutritious and appetising food was being served. Residents are supported in deciding where they wish to eat their meal. The fruit bowls were Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 13 full on the occasion of both visits. One relative did comment that more salads and fruit would be welcome. On the second day of the inspection the Inspector met with three relatives visiting a parent at the care home. The feedback was positive about the welcome received by relatives visiting family members. One relative spoke positively about being made most welcome, being given tea and biscuits whilst seeing her father in the privacy of his own bedroom. She described the atmosphere as being warm and friendly. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are aware of the homes complaints policies. Adult protection policies are in place for service users although some work is needed on POVA procedures. EVIDENCE: Relatives spoken to have commented that the current Manager is open to handling informal complaints or discussion on areas of improvement in the running of the care home and expressed confidence that she would tackle any concerns about residents’ wellbeing. The complaints procedure was displayed in the hall and the policy was looked at by the Inspector in the policy and procedures manual. There was only one complaint in the last 6-month period and the manager of the care home dealt with this firmly and promptly. The Manager of the care home is currently undertaking some further work on the recording and processing of complaints. There have been no protection of vulnerable adult referrals since the last inspection. There is a policy and procedure in place; however work is needed on recording any POVA incidents that might occur at the care home. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents say they are comfortable; they can personalise their rooms, although some area of the home will need ongoing work to ensure service users live in a quality environment. The home is generally clean, tidy and hygienic EVIDENCE: A partial tour took place of the premises by the Inspector. It was only partial given the Inspector had undertaken a tour of the premises on several occasions since the last inspection. The inspector noted that the varnish on the front door is patchy and poor and does not give a good first impression and along with the front step threshold needs to be refurbished. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 16 There are plans to change the carpet in the living area as it was becoming worn. It is positive to note that both the proprietor and the manager have made efforts to improve the quality of the environment for the service users over the past months. There was concern at four previous visits going back over two years that the replacement mattress was soft and had not been replaced with a suitable mattress. This has not been replaced and this must be rectified. A pressure-relieving mattress had been placed on top. The resident using the room said that he had experienced the arrangement initially as not feeling fully secure. The home at the time of both inspections was clean pleasant and hygienic. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 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. 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. The service recognises the importance of training. There are some areas that need attention in the home’s recruitment practices to protect service users.. Residents are generally satisfied that the care they receive will meet their needs. EVIDENCE: A long-standing requirement has been that the Proprietor/Manager must carry out spot night checks and must provide evidence of the findings. This has now happened on one occasion. A pattern now needs to be established of visits and fuller reporting of these visits. A recommendation that has remained is the need for the staff rota to cover a one-month period. The Manager of the care home is taking forward the training needs of the staff group. She has signed up for ‘Care to Lead’ which is a Training Needs Analysis and Organisational Development and Training Plan for staff working in the care home. This includes an analysis of business, employee development, Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 18 organisation development and training plan, summary of training needs analysis. The Manager has made a commitment to encouraging and supporting staff undertaking NVQ 2 training. The Inspector looked at two staff files. Two requirements arose. Neither file had a second reference (though a second reference had been obtained according to the Manager). One staff member did not have an up to date CRB check. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is developing systems and practice at the care home which is positive move for the staff and residents. The service aims to work in partnership with professionals and residents and their families. Some health and safety improvements need to take place and registration must match the client group served. EVIDENCE: Staff meetings have not been part of the culture of the care home in the past. The Manager has taken the need for staff meetings fully on board. A staff meeting took place on 8th November 2006 and a further staff meeting is planned. An agenda was drawn up, minutes taken and distributed by being Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 20 stapled to each staff member’s payslip. Items discussed were mainstream issues around communication, training role of key workers, recording, missing items of clothing etc. The fire alarm was tested on 30/3/06. The chair lift is subject to a service contract that expires at the end of 2007. One staff member leads on a weekly test of fire alarms. Fire drills are happening monthly. No current electrical testing or portable testing certificate were available for inspection. These need to be current and available and should be addressed as a matter of urgency. The Inspector looked at Resident’s finances and inventory of valuables at the previous additional visit. It was noted by the Inspector that several residents who had been admitted to the care home either on a permanent basis or as a respite stay were under 65 with dementia. The home is registered for Older Persons. An application for a variation of registration must be progressed promptly by the Proprietor and Manager in order that the care home is appropriately registered. Staff files would benefit from being indexed and kept in administrative order. The Manager has started undertaking giving relatives/friends/visitors a questionnaire on the experience of residents at the care home. This is providing useful feedback for raising standards. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 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 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 2 X 3 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 3 3 3 X 3 X 2 2 Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 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 OP8 Regulation 12(1) Requirement Weighing must take place monthly for all residents including the more physically disabled residents. (Previous timescales of 1/5/06, 31/7/06, 1/10/06 and 1/12/06 not met) A process for recording POVA incidents must be in placed in the home. The varnish on the front door is worn along with the threshold area being in need of refurbishment. The lounge carpet is need of replacement The replacement mattress is too soft and must be replaced. (Previous timescales of 31/1/05, 1/6/06, 31/7/06/ 1/10/06 and 1/12/06 not met) An up to date CRB check is need for all staff. Two references must be kept on the staff personnel files. An application form must be completed for a variation order to include residents with DS0000017443.V316304.R01.S.doc Timescale for action 01/03/07 2. 3. OP18 OP19 17(2) 23(2)(b) 01/02/07 01/03/07 4. OP24 23(2)(b) 01/02/07 5. 6. 7. OP29 OP29 OP37 19(4)(b) 19(4)(b) 23(1)(a)( b) 08/12/06 08/12/06 31/01/07 Roseland Care Home Version 5.2 Page 23 8. OP38 13(4)(c) dementia and residents under 65 with early onset dementia. Current up to date electric testing and testing of portable appliances must be in place. 08/12/06 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. 2. 3. Refer to Standard OP27 OP27 OP37 Good Practice Recommendations The staff rota should cover a one-month period. The Proprietor/Manager should establish a pattern of carrying out spot night checks, evidence of findings need to be provided. Staff records should be systematically laid out. Roseland Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Care Home DS0000017443.V316304.R01.S.doc Version 5.2 Page 25 - 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. 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