Inspection on 09/11/05 for Roseland Care Home

This inspection was carried out on 9th November 2005.

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

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

Other inspections for this house

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 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 Sue Mitchell Unannounced Inspection 9th November 2005 08:30 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.V263992.R01.S.doc Version 5.0 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.V263992.R01.S.doc Version 5.0 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 Ms Anne Elizabeth Montgomery Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 06/07/05 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 ensuite 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.V263992.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out from 8.30 am until 12.45 pm. The manager was on duty with two care staff. The cook and cleaner came in later on in the morning. The residents were in the process of getting up and having breakfast either in the dining room or in their rooms. The inspector spoke to one relative and several residents during the course of the inspection. The inspector also spoke to the care staff, one of who had recently been appointed. One resident became unwell during the inspection and the staff were observed to respond appropriately; calling the emergency services and relatives as well as remaining in contact with the hospital to check on the resident’s condition. The inspection focussed on following up the requirements that had been set at the last inspection as well as two additional visits. The inspector also toured the premises, checked records and care plans, staff recruitment and training records. What the service does well: What has improved since the last inspection? What they could do better: The previous inspections have focussed on improving standards relating to recruitment, care planning, policies and procedures, training and staff supervision. Much work has been done to meet these standards over the last Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 6 few months. A major part of this inspection focussed on assessing the residents’ environment. The proprietor is responsible for maintaining the building and contents. The inspection found major shortfalls in the quality of furnishings both in the communal and bedroom areas with a need to provide quality lounge and bedroom furniture, bed linen and towels for the residents. The windows require replacing throughout the home and redecoration of both bedrooms and communal areas is required to ensure the home meets the environmental standards. The kitchen requires full refurbishment. The proprietor must ensure that he assesses the premises as part of his monthly monitoring visits to ensure standards do not fall. The proprietor submitted policies on medication and quality assurance to the CSCI for comment. Work is still needed on these policies. A policy on managing verbal and physical abuse in the home was a previous requirement and has not been achieved. In terms of quality assurance work is required to implement a monitoring system within the home. The home’s business and annual development plans have not yet been sent to CSCI as required from previous inspections. The manager needs to ensure that the residents have activities organised for them on a daily basis. A video player and new games to stimulate the residents interest must be purchased. Staff are now beginning to have supervision and new staff are being inducted. The manager must ensure that she keeps a record of induction and includes information on the homes complaints and adult protection policies. 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.V263992.R01.S.doc Version 5.0 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.V263992.R01.S.doc Version 5.0 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 residents care needs are assessed prior to admission either in their own home or current place of residence. Relatives are involved as appropriate. EVIDENCE: The manager has now implemented a needs assessment format, which she is using for new admissions as well as to reassess the current residents. The care file of the most recent admission was sampled. This person was admitted from hospital and was receiving support from the district nurse in the home (see standard 8) The needs assessment included all aspects of personal care needs as well as more specialised support for catheter care. Risk assessments were also in place and a care plan had been written for this person. The home had been required to develop their referral, assessment and introduction policy into one document. This had not been achieved. Some information was in the Statement of Purpose but this did not fully cover the referral and admission process. This is outstanding and must be achieved within the stated timescales Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 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): 7,8,9,10 All residents have a care plan in place, which are being reviewed regularly. They are able to access all community health care services. Residents are treated with respect by staff and have positive relationships with them. The medication policy is now in place and administration practices are safe. EVIDENCE: The manager has now completed care plans for each resident, which had been required from the last inspection. She is now in the process of evaluating and reviewing the care plans on monthly basis. There was evidence that this was being carried out in the care plans sampled. Residents are also involved in these reviews as well as families as appropriate. Residents sign the care plan/review where possible. The residents’ health care records and appointments were made available for inspection. These were clearly recorded. One person has input from the catheter care nurse. The manager was advised to record these routine visits. The district nurse also visited the home during the inspection and stated that she was pleased with the care provided. There were no pressure sores in the home at this time. The home has good support from the GP and the residents have regular dental, chiropody and optician appointments within the home. Information on the residents’ dietary needs and preferences are in the assessment and care plan. The manager stated that residents are weighed if Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 10 there are concerns about weight gain or loss. There are no weight charts at present in the files. The manager must ensure that a monthly record is kept of resident’s weight. The manager said it was difficult to weigh some people due to their physical disability and would have to take them to the clinic to do this. The manager should seek advice from the district nurse regarding this issue. She said that with such a small group of residents it wasn’t difficult to monitor their food and fluid intake and that they would refer them to the GP if there were any concerns about weight etc. The medication policy had been sent to the CSCI pharmacy inspector, she had required some minor amendments, which the manager stated the proprietor was overseeing. The proprietor must send a copy of the completed polices to the CSCI office. The manager stated that the supplying pharmacist was to come into the home to carry out staff training on the new monitored dosage system. All the residents who were able to speak to the inspector stated that the staff were caring and respectful. They praised all the staff for the care given and said that their needs were being met. The relative who visited also stated that she was pleased with the care provided. Staff were observed to speak in a caring manner to residents. Some of the residents had lived in the home for some time and it was clear that they had developed positive relationships with the staff. There was a relaxed atmosphere in the home with the staff, including the cook and cleaner, and residents interacting together positively. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 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): 12,13,14,15 Residents do not have regular organised activities at present. Relatives are made welcome within the home. Residents are able to make day to day choices. The residents receive freshly cooked meals of their choice. EVIDENCE: A relative had contacted the inspector prior to the inspection and raised some concerns about the lack of activities for the residents. The relative was a regular visitor and felt the residents would benefit from some games or activity to stimulate them. The manager stated that the she was aware that some of the residents would benefit from more activities and had already got tickets to a wartime musical for the following weekend. Seven residents were going with staff. She had also booked an accordion player to come in for December and was exploring other groups to come in especially around Christmas. A number of the residents are very elderly and need to be encouraged to join in with activities. It was recommended that she identify two regular staff to plan activities for the afternoons. There must be a list of the week’s activities on display for visitors and residents to see. Staff must record that the activities have taken place and who participated. The home has some games but these should be checked to see if they were appropriate. The manager said she would also look at getting some new games like Bingo and reminiscence cards/games. There is no video in the home. This is required, as residents may prefer to watch old films or musicals rather than TV. This would also stimulate discussion amongst the residents and staff. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 12 The home welcomes visitors at any time, but does ask them to respect resident’s privacy during meal times. The relative who visited said she was made welcome, and that staff contact them if there are any concerns about her relative. The residents spoken to said they had family and friends who visited regularly and that they also went out with their families and friends. There is information on how to contact advocacy services in the service users guide. Information on how resident’s finances are managed is also available. The home only manages small sums to assist with purchasing newspapers, hairdressing etc. The inspector observed that the majority of residents had some personal possessions in their rooms. The home has a cook Monday to Friday and staff prepare meals at the weekends. The manager was concerned that staff have to cook and clean as well as care for the residents at weekends when there are only two carers on duty n each shift. The proprietor must ensure that there are sufficient staff on duty to meet the standards relating to food, meals and nutrition and that the home is kept clean and free form dirt and unpleasant odours. The cook had been on sick leave the previous week and a new menu was not available. The manager stated that she and the staff had covered this whilst also caring for the residents. The previous week’s menu was on display and showed a range of traditional meals. The residents were having breakfast when the inspector arrived and had cereals, toast etc. Lunch was steak and kidney pie with fresh vegetables and stewed apple and custard for dessert. The residents spoken to all stated that they enjoyed the food in the home. Residents were observed being offered drinks and snacks throughout the day. The person who is a vegetarian stated that she always has what she prefers to eat every day. The cook spoke knowledgably about the residents’ food preferences and dietary needs. She has worked in the home for a number of years and knows the residents well. There is no list of these dietary needs and preferences. This is required. One person is vegetarian and there is one person with diabetes. Some residents require their food to be pureed and one person needs to be fed by staff. The manager has had training on diabetes as has some of the staff. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 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 Residents and relatives are informed of their right to complain or raise concerns. Staff are aware of their responsibility to ensure residents are protected from abuse. EVIDENCE: The manager was required to carry out in house training on the homes complaints procedure and recording. She stated that this had now been carried out with the staff group. The two new staff should also have this training as part of their induction. None of the residents wished to raise any complaints or concerns with the inspector on this occasion. The manager stated that two staff had now attended PoVA training and she was looking to send all the staff on the training when it became available. The inspector recommended that the manager to meet with the staff to go through the homes adult protection policy as a matter of good practice to ensure they were clear about the issues involved. This must also be included in the induction package for new staff. The inspector spoke to the new member of staff who was able to demonstrate a working knowledge of adult protection. Policies on the management of verbal and physical abuse were required to be written at the last two inspections. This has not been achieved and is required to be completed within the timescale stated. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 14 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): 19,21,22,23,24,26 The residents live in a clean tidy but poorly maintained environment, which would benefit from major refurbishment throughout. EVIDENCE: The proprietor is responsible for maintaining the building and contents. The inspection found major shortfalls in the quality of furnishings both in the communal and bedroom areas with a need to provide quality lounge and bedroom furniture, bed linen and towels for the residents. The windows require replacing throughout the home and redecoration of both bedrooms and communal areas is required to ensure the home meets the environmental standards. The kitchen requires full refurbishment. Full details of all the work that is required can be found in the requirement section of the report. The proprietor must ensure that he carries out the repairs, replacement or refurbishment of the items identified within the timescales stated in order to meet the National Minimum Standards and Care Homes Regulations and to provide a quality environment for residents. A letter identifying some of the more urgent issues was sent to the proprietor following the inspection. A response has been received. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 15 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. The home was clean, tidy and free from odours during this inspection. The residents did not raise any issues regarding their rooms during the inspection although the relative did feel that the home was shabby. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 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 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): 27,28,29,30 The residents are supported by a caring group of staff that have received appropriate training. Staff have the appropriate checks prior to starting work in the home. EVIDENCE: There had been two new staff appointed since the last inspection. Their personnel records were made available for inspection and found to be in order with the correct recruitment checks in place. Both staff are in the process of completing their NVQ 3 using their own resources. It was recommended that the proprietor/manager keep a checklist of recruitment information that has been received or requested so that they can ensure that all checks are received prior to staff starting work in the home. The manager had been required to provide a training programme for the home. This has not been achieved. The inspector was informed that staff are having core training such as first aid, moving and handling etc. The manager is in the process of meeting with staff to assess their training needs to identify what training will be required the following year. The staff member spoken to stated she was having induction with the manager. A record of the staff induction must be in their files. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 17 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): 33,35,36, The residents, relatives, staff and other stakeholders are not consulted about the running of the home. The homes policies are now accessible. EVIDENCE: The proprietor had sent the CSCI office a copy of the home’s quality assurance policy. This was judged to be inadequate and the inspector has written to the proprietor with comments on the policy for him to action. A copy of the amended policy must be sent to the CSCI office when completed. The annual development plan and business plan had not been submitted as required from the last inspection. The homes policies are now available for staff to access and for inspection. A number of the policies are out of date and need to be reviewed to ensure they correctly reflect the National Minimum Standards and Care Home Regulation. This is ongoing work and will be reviewed at each inspection to ensure that the policies and procedures are being updated. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 18 The inspector sampled the resident’s finances and records held in the home. The home only manages small sums on behalf of the residents for purchasing newspapers, hairdressing toiletries etc. There were clear records of all transactions. The manager stated that she is in the process of meeting with staff as a part of the supervision process. Records were made available of these meetings. Health and safety standards had been fully assessed at the last inspection in July 2005. The proprietor had been required to ensure that all certificates relating to the appliances and equipment used were made available for inspection at any time. These certificates were now held in the office. Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 19 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 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 1 X 1 X 1 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 X X Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 20 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 31/01/06 2 3 OP8 OP9 4 OP12 5 6 7 OP12 OP15 OP18 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 timescales of 30/04/05 and 31/08/05 expired) 12(1) The manager must ensure that a monthly record is kept of resident’s weight. 13(2) The proprietor must send a copy of the amended medication and homely remedies policies to the CSCI office.(Letter sent with comments on 03/11/05) 16(m) There must be a list of the week’s activities on display for visitors and residents to see. Staff must record that the activities have taken place and who participated. 16(m) A video and games suitable for the residents must be purchased 16(2)(i) A list of the residents’ dietary 17(2) needs and food preferences must be available. 12(1)(2) Policies on the management of verbal and physical abuse must DS0000017443.V263992.R01.S.doc 30/11/05 31/12/05 30/11/05 30/11/05 30/11/05 31/01/06 Roseland Care Home Version 5.0 Page 21 8 OP19 23(2)(b)(c ) 9 10 11 OP19 OP19 OP19 23(2)(b)(c ) 23(2)(b)(c ) 23(2)(b)(c ) 12 13 14 15 OP19 OP19 OP20 OP20 23(2)(b) (c) 23(2)(b) (c) 23(2)(b) (c) 23(2)(b) (c) 16 OP20 23(2)(b) (c) 17 OP20 23(2)(b) (c) 18 OP20 23(2)(b) (c) be written. (Previous timescales of 31/05/05 and 31/08/05 not met) The kitchen linoleum must be replaced, it is cracked, and worn and presents as a health and safety hazard being liable to harbour dirt and become a tripping hazard. The door to the boiler, must be replaced. The kitchen ceiling is stained and must be redecorated The kitchen cupboards are not secure. They do not close and present as a health and safety hazard to staff working in the kitchen should they swing open. The cupboard doors must be made safe The kitchen work surfaces and cupboards must be replaced, as they are worn and shabby. The handle on the laundry door must be repaired The two lounge chairs, which are split, must be replaced The lounge must be redecorated. The addition of a wooden dado rail to the walls would prevent the residents’ chairs marking and damaging the walls. Internal doors and walls must be protected from damage by wheelchairs by the use of Plexiglas or similar within the home. All the window frames within the house must be replaced. The woodwork was noted to be rotten and the paint is peeling. The proprietor must ensure that window restrictors are put on all the windows. The carpet on the landing by the upstairs landing is threadbare and will present as tripping DS0000017443.V263992.R01.S.doc 31/01/06 31/12/05 31/12/05 31/12/05 31/03/06 30/11/05 12/12/05 31/01/06 31/01/06 31/03/06 Roseland Care Home Version 5.0 Page 22 19 20 21 OP20 OP22 OP24 23(2)(b) (c) 23(2)(i) (n) 16(2)(c) 23(2)(b)( d) hazard if not replaced within the timescale stated The stair carpet is also in a similar condition and will require replacing as above. The grab rail in the downstairs toilet must be repaired as it is not usable at present All the residents’ bed linen must be replaced with matching duvet covers, valances, sheets and pillowcases. All the residents’ towels and flannels must be replaced with better quality items. 31/01/06 31/03/06 30/11/05 31/12/05 22 23 OP24 OP24 16(2)(c) 23(2)(b)( d) 16(2)(c) 23(2)(b)( d) 24 OP24 16(2)(c) 23(2)(b)( d) 16(2)(c) 23(2)(b)( d) 16(2)(c) 23(2)(b)( d) 25 26 OP24 OP24 Room 5: The two bed bases must be replaced as the fabric is worn and stained. Room 10: The mattress was very soft and the quality of the bed base was poor. It is on wheels and could present as a health and safety hazard. These must be replaced. The proprietor must purchase furniture that is appropriate and suitable for residents needs. (Letter sent to this effect on 10/11/05) Room 9: The bed base must be replaced Room 3: the bed provided was seen to be inappropriate, having been purchased as a second hand item. There was no bed base. A new bed must be purchased. The flooring had been replaced as recommended at the last inspection, as the resident was incontinent. The replacement flooring was seen to be inappropriate, being of industrial quality and was clearly not new as there was a poorly repaired tear in one corner. This DS0000017443.V263992.R01.S.doc 31/12/05 31/12/05 10/11/05 31/12/05 31/12/05 Roseland Care Home Version 5.0 Page 23 27 OP24 16(2)(c) 23(2)(b)( d) 16(2)(c) 23(2)(b)( d) 28 OP24 29 30 31 OP24 OP24 OP27 16(2)(c) 23(2)(b)( d) 16(2)(c) 23(2)(b)( d) 18 must be replaced with cushion flooring in keeping with the bedroom. The resident’s family must be consulted regarding this if the resident is unable to make an informed choice. Room 1: One window is of reinforced glass (wire mesh) and is inappropriate for a bedroom. This must be replaced with clear glass. Room 4: The door must be repaired / replaced due to damage caused by the resident’s wheel chair being pushed against it. The bedroom wall was also similarly marked by the wheelchair and must be redecorated. Room 6: The window was also of reinforced glass and must be replaced. Room 6: The door handle must be replaced, as it is very loose The proprietor must ensure that there are sufficient staff on duty to meet the standards relating to food, meals and nutrition and that the home is kept clean and free from dirt and unpleasant odours 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. The manager must ensure that the induction programme includes information and training on the complaints and adult protection procedures A record of the staff induction must be in their files. 31/03/06 31/12/05 03/03/06 31/12/05 31/12/05 31 OP33 26 30/11/05 32 OP30 18 31/12/05 33 OP30 18 A formal training programme for DS0000017443.V263992.R01.S.doc 31/12/05 Page 24 Roseland Care Home Version 5.0 34 OP33 24 35 36 OP34OP33 OP33 24,25 24 the home must be in place (Previous timescale of 31/05/05 and 30/09/05 not met). A copy of the amended Quality Assurance policy must be sent to the CSCI office (letter with comments sent to home 03/11/05) The annual development plan and business plan for the home must be sent to the CSCI office The homes policies and procedures manual must be reviewed and updated. This will be reviewed on each inspection to ensure policies meet NMS 31/12/05 31/12/05 31/03/06 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 4 Refer to Standard OP8 OP8 OP12 OP18 Good Practice Recommendations The manager is advised to record routine visits from the catheter care nurse in the health care appointments folder The manager should seek advice from the district nurse regarding weighing the more physically disabled residents It was recommended that the manager identify two regular staff to plan activities for the residents during the afternoons It is recommended that the manager meet with the current staff to go through the home’s adult protection policy as a matter of good practice to ensure they are clear about the issues involved. It is recommended that the proprietor/manager keep a checklist of recruitment information that has been received or requested so that they can ensure that all checks are received prior to staff starting work in the home. 5 OP29 Roseland Care Home DS0000017443.V263992.R01.S.doc Version 5.0 Page 25 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.V263992.R01.S.doc Version 5.0 Page 26 - 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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