Inspection on 06/07/05 for Roseland Care Home

This inspection was carried out on 6th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 11/04/06

Roseland Care Home 09/11/05

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 Sue Mitchell Unannounced 6 July 2005 09:30. 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 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 G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Roseland Care Home Address 57 Draycott Avenue Kenton Middlesex HA3 0BL 020 8907 4080 020 8959 1249 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Jerome Manuel Ms Anne E Montgomery CRH - PC ONLY (Care Home) 10 Category(ies) of Old Age, not falling within any other category registration, with number (OP) of places Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29/3/05 Brief Description of the Service: Roseland care home is situated in a busy residential road off Kenton Road. It is a detached house consisting of two floors, i.e. ground and first floor. It has a total of one double and eight single bedrooms. There is a large lounge and separate dining area as well as a kitchen, laundry and 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 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 G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out during the morning and early afternoon. There were 8 residents in the home with one vacancy and one person in hospital. The manager and one carer were on duty. There was also the handyman, a part time domestic and cook in the home. The inspector met with 5 residents and spoke with them about the care provided in the home. All were very positive about the staff, care and meals. A complaint had been made to the CSCI in relation to contracts, reporting of incidents and accountability within the home. These were investigated as part of the inspection. The inspection focussed on following up the complainant’s issues, compliance with previous requirements, care plans, health and safety issues, recording and reporting issues, staff training and supervision and medication. Nine immediate requirements were issued at the inspection. A follow up visit was carried out on 26th July where another six immediate requirements were issued. Another visit was made on 3rd August 2005 to follow up the requirements set at the 26th July visit. It was positive to note that the proprietor and manager had complied with the majority of the immediate requirements from the two follow up visits. What the service does well: What has improved since the last inspection? What they could do better: At this inspection nine immediate requirements were issued.. These were about contracts not being given to relatives and residents, the lack of care plans and risk assessments, training for staff in complaints, abuse awareness and reporting of significant events to the CSCI, and the absence of service records and polices within the home. The inspector was concerned that the Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 6 manager had not been supported by the proprietor to meet previous requirements by ensuring she was able to work off rota for one shift per week. This is an outstanding requirement from inspections in August 2003, August 2004 and March 2005. An immediate requirement was also issued regarding this matter. An announced additional visit was made to the home on 26th July 2005. The purpose of the visit was to verify whether the immediate requirements had been achieved. This visit identified major short falls in the homes recruitment processes. The proprietor had appointed five staff since the inspection on 6th July. Four people had not had CRB and PoVA checks, there was no evidence that references had been taken up and application forms were not completed in full. The proprietor was informed that none of these staff was to work in the home until all checks have been carried out satisfactorily. Staff files were required to be up to date and made available for inspection on 3rd August 2005. Six immediate requirements were made in respect of these poor recruitment issues. In addition the inspector was concerned that only five of the previous immediate requirements issued on 6th July 05 had been achieved within the stated timescales. The inspector was pleased to note that at the follow up visit on 3rd August 05 all six immediate requirements had been met. A number of requirements from that visit relating to the premises and staff training were made and a letter sent to the proprietor for action. 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 G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 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 standard(s) 2,3 Residents and their relatives do not have the security of a written contract with the home. There are no records of residents having a needs assessment prior to moving into the home. Care plans do not evidence that their needs are being met. EVIDENCE: A complaint had been made to the CSCI about not receiving a contract from the home detailing information about the fees, terms and conditions. The manager stated that there were contracts available but that the proprietor dealt with this. The inspector was given a copy of the homes contract. None of the current residents had contracts on their files and the manager said that none of the new admissions had received a contract on admission. An immediate requirement was issued requiring the proprietor to issue contracts to all current residents and their relatives and to ensure that all new admissions received a contract, which is signed by either the relative or resident as appropriate. The manager has stated in previous inspections that she does visit prospective residents but did not keep a record of her assessments. The manager had been required to produce a needs assessment format, which would be used to assess new residents. This had not been achieved. She showed the inspector Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 9 draft documents of assessment forms, which she was planning to use. Four new people had been admitted to the home following the last inspection. None had had formal needs assessment carried out. One was an emergency six weeks ago but there was no paperwork or assessments on this person, nor was there a care plan, although a review had been carried out by Social Services. One person had transferred from another home with a detailed care plan but there was no evidence that the manager had carried out a needs assessment or written a care plan. One person was placed temporarily, but again there was no documentation to evidence that the home could meet their needs. The fourth person had moved on shortly after admission. The requirement to devise a needs assessment format and to do assessments prior to admission was outstanding from August 2004. The manager stated that she was unable to do this work due to being on shift each day, caring for residents and managing the day-to-day running of the home. The March 2005 inspection had required the proprietor to allow the manager one shift a week to catch up on outstanding work and carry out her management tasks which included assessing clients and writing care plans. The manager stated that she had only been given two half shifts to do this work and had been unable to complete it as she was put back on shifts by the proprietor. An immediate requirement was issued to ensure that the manager was given a shift per week to carry out her management tasks. A second immediate requirement was issued to ensure that all the new residents had needs assessment carried out on them and to write care plans and risk assessments for all the residents. The home had complied with the requirement provide all residents and relatives with contracts by the time of the additional visit on 26th July was carried out.. Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, Residents care needs cannot be met in full without clear and up to date care plans and risk assessments. Residents are now protected from harm by a more efficient medication system. Work is outstanding on the medication policy EVIDENCE: At the time of this inspection the manager explained that she had only had a short time allocated to draft a format for the new care plans. At the additional visit on 26th July 2005 three care plans and risk assessments had been written. She planned to complete the care plans when given the time off rota. Work is required to ensure the care plans are evaluated on a monthly basis and reviewed regularly. Care plans will continue to be monitored through the inspection process. The manager had started the process of recording all the residents’ health care appointments on separate sheet by the time of the additional visit on 26th July 05 (this was required at the 6th July inspection as an immediate requirement). The home now has a Monitored Dosage System in place, which the manager stated was working well. Medication records were checked and found to be up to date. The medication policy was not yet available. The proprietor said that he had completed this and was asked to send it to the CSCI Pharmacist Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 11 inspector. This is outstanding from the previous two inspections. It must also include a homely remedies policy and have GP approval for the use of over the counter products in the home. The manager was advised to contact the pharmacist to arrange for training on the use of the new monitored dosage system. At the additional visit the manager stated that she had contacted the pharmacist and was arranging a time for him to come in to train the staff. At the 3rd August visit the manager stated that she had discussed the homely remedies policy with the GOP who will be assisting her with this on his return form annual leave Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 The residents have access to a range of activities within the home of their choice. Details of their preferences are recorded on their care plans. EVIDENCE: At this inspection no work had yet been undertaken to include resident’s social and leisure interests on their care plans. However the second visit on 26th July found that the care plans now reflected this information. On the first visit a layperson had come in to carry out Holy Communion with the residents who wished this service. One resident spoke to the inspector and said she was going out with a friend for lunch. She was also very positive about the care and staff in the home. Most of the residents have a daily newspaper. One person said she was happy to be in the home as it was small and stated that she had plenty to do although she could not get about as much being in wheelchair now. The majority of the residents are very elderly and stayed mostly in the lounge watching TV, listening to music or chatting to staff and each other. Staff were observed to spend time chatting with them or reading the paper to them. There were board games available for the residents. Music played in the background. The TV was on after lunch and staff were heard to discuss the news items with the residents. Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 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 standard(s) 16,18 Complaints made by relatives or friends are not recorded or acted upon in a timely manner. Adult protection procedures are not followed by the proprietor or staff appropriately. EVIDENCE: A complaint and an allegation of abuse had been made to CSCI about the home. The home had not reported the allegation to CSCI. The complainant wanted her complaint investigated by CSCI. The inspector informed the Brent PoVA team, and the police are now investigating the allegation. The inspection found that staff had not recorded the complaint when it was made initially. There was no record in the daily record book of any untoward incident or behaviour regarding the resident on the day in question. There was no record of any investigation undertaken by the home. The proprietor stated that he, not the manager, had carried out an investigation into the matter. There was no written record available of this investigation. He was reminded of the duty to report any PoVA incidents to CSCI and to have a record of any investigation available for inspection by the appropriate authorities. One staff member questioned said she did not know of the home’s adult protection policy and procedures. The manager had recently attended abuse awareness training but staff have not as yet received any adult protection training. This is an outstanding requirement from previous inspections. An immediate requirement was issued on 6th July for staff to have in house training on recording of complaints, allegations and the reporting of all Regulation 37 significant events to CSCI within 24 hours. Staff must also be given information on the homes adult protection policy as part of their induction and be ongoing. The home had not complied with the above by the Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 14 time of the additional visit on 26th July 2005. The manager stated that she had not been given sufficient time off rota to do this with the staff as she was also trying to write care plans and risk assessments. The proprietor had stated that he would be reporting all Regulation 37 incidents to the CSCI instead of the manager in future in his action plan response to the immediate requirements. The policy on handling resident’s money was also not in place. The proprietor stated that he had this at home. He was reminded that all policies relating to the running of the home and residents welfare must be in the home and made available to staff to refer to and for inspection at any time. This is outstanding and was made an immediate requirement on 6th July 05. At the time of the additional visit on 6th July 05 the policies were still not in the home. The polices were in the home on the 3rd August visit and a new complaints book had been started. Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 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 standard(s) 19 The residents live in a homely environment, which is kept clean and free from odours EVIDENCE: A full inspection of the premises was not carried out on this occasion. The communal areas were noted to be clean and tidy. The manager stated that the ground floor shower floor had been lowered for easier access for the less mobile residents. None of the other proposals discussed at the last inspection to improve the home such as a new kitchen, double-glazing or a walk in shower room on the first floor had been actioned. The proprietor was not available to discuss these issues on this occasion. The Environmental Health Officer and Fire Officer had recently visited the home. Copies of their reports were not available for inspection. This is required. These were provided at time of the additional visit on 26th July 05 The home was clean and free from odours at the time of the inspection. Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Residents are at risk from harm through the homes inadequate recruitment procedure. Staff do not receive scheduled training in order to protect the residents. Staff are not given appropriate one to one supervision to carry out their jobs EVIDENCE: The proprietor had been required to ensure that the manager had a least one shift per week to carryout her management role, which included formal staff supervision, in house training, policy writing, care planning and risk assessments (see standards 3, 6,7,9) The manager stated that she had only been given half a shift (3 ½ hours on two occasions) since the inspection in March 2005. An immediate requirement was issued to ensure that the proprietor provides cover for the manager to work off shift to carry out the tasks identified in this and previous reports. The inspector was concerned to hear that at the additional visit on 26th that the manager had only had ½ a shift since the 6th July inspection to do any work on care plans or any of the other immediate requirements regarding training etc. This was discussed again with the proprietor at the additional visit and included in the letter sent to the proprietor following the visit. At the 6th July visit there were no new staff. The inspector had been informed that 5 new staff had been appointed since that visit and had required the proprietor to produce evidence of appropriate recruitment checks carried out prior to these staff starting work. On the day of the visit the inspector was concerned to find none of the staff appointed had had full recruitment checks carried out i.e. CRB, PoVA list checks, two references taken up or application Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 17 forms completed in full. There was no evidence that any references had been taken up. One staff member was working nights with no evidence of any checks being carried out. The proprietor was informed that all these staff must cease work in the home immediately. A number of immediate requirements were issued in relation to recruitment checks being carried out on these staff. The proprietor informed the inspector that he interviewed staff not the manager. This was of concern to the inspector, as the manager has no say in the suitability of staff employed in the home and whether they had relevant experience in working with older people. The job description supplied following the last inspection states that recruitment and interviewing of staff is her responsibility. In addition the staff rota indicated that some staff were working more than 48 hours per week. The proprietor was required to provide evidence that staff have signed a contracting out agreement to enable them to work more than 48 hours. The proprietor had complied with the majority of the recruitment requirements by the time of the 3rd August visit. Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,35,36,38 Resident’s health, safety and welfare are not fully protected. Staff are not formally supervised to ensure that they carry out care appropriately. Lack of management time has meant a shortfall in carrying out requirements relating to how the home is run. EVIDENCE: As stated in previous standards the manager is unable to carry out her management tasks in full due to working on shifts. The requirement to provide cover for the manager to carry out these tasks is outstanding from August 2004. Some shifts off rota have been arranged but these are not consistent. Staff do not have formal supervision, this has been a requirement since August 2003. The manager works morning shifts with staff and oversees their work but there is no opportunity for one to one discussion with staff. None of the residents is under Court of Protection. The manager is not an appointee for any of the residents. Relatives manage the financial affairs and the home looks after any money handed in for hairdressing, clothes, toiletries Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 19 etc. A sample of records was examined. These were detailed and found to be accurate on the day. A policy on managing resident’s money is outstanding from the previous two inspections. None of the certificates relating to equipment and appliances used in the home was available for inspection. An immediate requirement for these to be kept in the home was issued on 6th July 05. The proprietor supplied the information at the visit made on 26th July 05. A fire risk assessment was not in place at the 6th July visit, one was made available at the 26th July visit. Fire drills and weekly fire checks are carried out. There is a handy person available to carry out any minor repairs etc. The manager stated that COSHH data was being obtained slowly due to the lack of management time. Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 1 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 1 1 1 2 2 1 1 x 3 Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 21 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 3 Regulation Requirement Timescale for action 31.8.05 2. 9 3. 9 4. 18 5. 18 6. 30.16, 14(1)(a)(c The three documents that ) referred to the referral,assessment and indroduction to the home must be reviewed and an agreed policy put in place.(previous timescale 30.4.05 expired) 13 A copy of the medication policy must be sent to the CSCI pharmacist (Previous timescale of 31.5.05 expired) 13 A homely remedies policy must be in place. All over the counter remedies must be approved by the GP. 12 The policy on service users finances and managing verbal and physical abuse must be written within timescales stated (Previous timescale of 31.5.05 expired) 18(c) Staff must attend abuse awareness training (Previous timescales of 31.5 05 and 22.7.05 expired) 18(c), 37 Staff must have training on complaints reporting and recording, reporting and recording of incidents and understanding of the requiremnet to report all G62-G11 S17443 Roseland V236914 060705 Stage 4.doc 31.8.05 31.8.05 31.8.05 31.8.05 31.8.05 Roseland Care Home Version 1.40 Page 22 7. 32 8. 31 9. 29 10. 29 11. 27 12. 30 significant events to the CSCI within 24 hours 12(1)(b) All policies relating to the running and management of the home and to resiodents care must be in the homeand made availble forinspection at any time and be accessible to staff at all times. (Previous timescale of 22.7.05 expired) 12(1)(a) The manager must have a minimum of one shift off rota per week to carryout her management tasks as identified in previous inspections namely: one to one staff supervision, care planning, risk assessments and needs assessments of new residents, policy and procedure writing and in house staff training. (previous timescales of 1.4.05,22 7.05 expired) Schedule Recruitment checks must be 2 carried out in full on all new staff prior to starting work in the home Schedule Staff files must contain all the 4.6 information as detailed in Schedule 4.6 for all staff employed from 1.4.02 European There must be evidence that Working staff have signed a contracting Time out agreement to enable them to Directives work more than 48 hours per Regulation week. s 1998 18(c)iand A formal training programme is ii required to be in place. (Previous timescaleof 31.5.05 expired) Staff must have individual training and development asessments (Previous timescaleof 31.5.05 expired) The manager and proprietor must seek out an appropirate quality assurance system to ensure the home is meeting the G62-G11 S17443 Roseland V236914 060705 Stage 4.doc By 9.8.05 From 6.7.05 and be ongoing From 27.7.05 and ongoing 3.8.05 3.8.05 30.9.05 13. 33 24 30.9.05 Roseland Care Home Version 1.40 Page 23 14. 34 25(2)(e) 15. 36 18(2) 16. 38 37(a-g) aims and objectives and statement of purpose of the home (previous timescale of 31.5.05 expired) An annual development plan for the home is required. (Previous timescale of 31.5 05 expired) A business plan for 2005-6 must be made available for inspection (previous timescale of March 2005 expired) The homes supervision policy must be fully implemented. Staff must be formally supervised at least 6 times a year. Records must be made available for inspection.(Previous tiomescaleof 1.4.05 expired) The home must adhere in full to the reporting of all significant events in relation to Regulation 37 30.9.05 From 31.8.05 and ongoing from 6.7.05 and ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Roseland Care Home G62-G11 S17443 Roseland V236914 060705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 4th 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. 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