Inspection on 10/11/05 for Roselands

This inspection was carried out on 10th 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

Roselands 19/06/06

Roselands 07/10/04

Roselands 06/05/04

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 Roselands 8-10 Stanford Road Norbury London SW16 4PY Lead Inspector Peter Stanley Unannounced Inspection 10th November 2005 9:30 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 Roselands DS0000025830.V264308.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. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Roselands Address 8-10 Stanford Road Norbury London SW16 4PY 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 8764 6045 NO FAX Mr Nizma Hosanee Mrs Zeidah Bannon Hosanee Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2005 Brief Description of the Service: Roselands is a 16 bedded domestic-style building within a residential street, very closely situated to the busy Norbury High Road shopping area and to excellent transport links formed of a number of bus routes to Croydon, Brixton, Clapham and Central London and the railway link to Croydon, Thornton Heath and Central London. The home comprises two interconnected houses, with three floors being accessed via a passenger lift. Each floor provides a large lounge and dining area, service users move between these lounges, with the ground floor lounge providing the social focus of the home. The home provides bathrooms and toilets on each floor, or on half-landings between floors. The home aims to accommodate more able older people, and is not suitable for people who have a physical disability as the home is accessed from the front by a small number of stairs. Many of the home’s service users are able to manage their own care, with service users being encouraged and assisted to access local community facilities. The home has a large and pleasant garden, which is well maintained. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on 10 November 2005. The inspection involved consultation with the care manager, Hannah Oozeerally, and discussion with service users and staff members on duty. The registered provider, Mr Nizma Hosanee, was on leave and not present. Service users again commented favourably about the care and support they receive at the home, and the caring attitude of the staff team. Staff on duty at the time of the inspection presented as skilled and professional in their approach, and were observed to be interacting with service users in a caring and respectful way. The inspector was impressed with the high standards of care and support provided, and with the open, friendly and inclusive atmosphere that characterises this home. One significant area of concern identified was the failure to have applied for a new criminal records bureau check for a recently recruited staff member. The inspector discussed this at length with the care manager and was assured that a new check will be immediately applied for and that correct procedures will be adhered to in the future. Four requirements and three recommendations apply from this inspection. What the service does well: Service users are being provided with the information, which they require, to enable an informed choice as to where they would like to live. Service users are being provided with a copy of the home’s terms and conditions at the point of moving into the home. The home is able to demonstrate that service users’ needs are being properly assessed, and that the range of needs presented is being sensitively and appropriately met. Service users are having their health, personal and social care needs set out in an individual plan of care, with review taking place on a monthly basis. The health care needs of service users are being fully met. The views and wishes of service users and their relatives, regarding the eventuality of the service user’s infirmity or death, are being respected. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 6 The home’s policies, procedures and practice evidence that service users are being protected from abuse and are living in a safe environment. Service users are being treated with respect and are having their right to privacy upheld. Service users are evidenced to live in a safe, well-maintained environment, with access to safe and comfortable facilities. Risk assessment of the home and individuals are in place for their protection. The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s service users, and to ensure their safety. Staff are being provided with the necessary induction and training with which to competently perform their work duties The home is being managed in the best interests of the home’s service users. The management approach is evidenced to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. Service users’ financial interests are being appropriately safeguarded. The inspector is satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. . What has improved since the last inspection? What they could do better: Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 7 Training in bereavement and loss would, however, assist staff in their support of service users when this eventuality arises. While the home has appropriate recruitment policy and practices in place, the protection of service users is placed at potential risk by the failure to have obtained an up-to-date criminal records check for new staff appointments. The quality assurance audit needs however, to be developed so as to clearly demonstrate the extent to which the home is meeting its aims and objectives. Re-carpeting of the hall and stairway areas is outstanding, and has been scheduled to be completed by Easter 2006. 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. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 8 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 Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 9 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): Service users are being provided with the information, which they require, to enable an informed choice as to where they would like to live. Service users are being provided with a copy of the home’s terms and conditions at the point of moving into the home. The home is able to demonstrate that service users’ needs are being properly assessed, and that the range of needs presented is being sensitively and appropriately met. EVIDENCE: Standards 1 to 4 were assessed. The home has compiled a statement of purpose outlining the aims and objectives of the home, and the facilities and services it provides. The Statement of Purpose includes all the information detailed in Schedule 1 of the Care Homes Regulations (2001). The home has developed a Service User’s Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 10 Guide which is written in a format/language suitable for the service users and contains all the elements of regulation 5(1),(2)&(3). Both the Statement of Purpose and the Service User’s Guide have been reviewed in 2005; the complaints policy and procedure included within the Service User’s Guide has been updated, and an addendum to the Statement of Purpose has been added, giving updated details of the qualifications and experience of the home’s management and care staff. All service users are issued with a Placement Agreement, which clearly sets out the terms, and conditions that apply to their placement in the home; this is written in plain English and is signed by the service user or his/her representative. Referring local authorities provide written contracts which provide detailed information relating to the legal basis and terms on which the placement has been agreed with the home and the service user. New service users are only admitted on the basis of a full assessment undertaken by a person who is suitably qualified to do so. The assessment is done with the service user, relative or delegated representative and relevant professionals that have been party to the referral. The home has admitted one new service user since the last inspection in April 2005. The inspector examined the service user’s file and found that a full care management assessment, outlining the service user’s care needs, had been obtained from the referring local authority, and that assessments and risk assessments had been completed by the home. These include a ‘choice assessment’ which includes very detailed and comprehensive information regarding the wishes and preferences of the service user in relation to their daily care, routines and activities. The Registered Provider is very clear about the range of needs the home will meet, thus the Statement Of Purpose states that the home will not offer placement to service users who have nursing needs, mental impairment and use wheelchairs. The Registered Provider aims to admit service users whose needs are similar to those of current service users. The service users of this home are very independent and relatively able. The home’s care manager was able to demonstrate the home’s capacity to meet the assessed needs of individuals admitted to the home. The inspector spoke to a wide range of service users. Many positive comments were made regarding the home and the care provided, with service users presenting as being very settled, content and well supported. Staff members on duty presented as caring and alert to individuals’ needs, and were observed spending time in engaging with service users. The various assessments (including choice, independence and service users’ rights) and service user plans indicate that service users needs are very well assessed and documented, with a wide range of individualised needs being addressed. Staff and training records indicate that the home has the range of skills abilities required to meet the needs of service users. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 11 Records of the service user’s initial six-weekly and subsequent three-monthly reviews were evidenced. Three monthly formal reviews are held to which the service user, his/her relatives/representatives, care manager and GP are invited. The GP attends all reviews. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 12 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): Service users are having their health, personal and social care needs set out in an individual plan of care, with review taking place on a monthly basis. The health care needs of service users are being fully met. Service users are being treated with respect and are having their right to privacy upheld. The views and wishes of service users and their relatives, regarding the eventuality of the service user’s infirmity or death, are being respected. Training in bereavement and loss would, however, assist staff in their support of service users when this eventuality arises. EVIDENCE: Standards 7, 8, 10 and 11 were assessed. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 13 Service users’ care plans are being compiled on the basis of the initial assessment prior to admission, on admission and during residency. Care plans are viewed by the home as being ‘living documents’. The inspector examined the care plan for a recently admitted service user. This evidenced the involvement of the service user and/or relative/representative in drawing up the care plan. Care plans set out the individual needs of the residents and how the home aims to meet them. These are being reviewed on a monthly basis. All care plans are signed by service users, with service users being given the choice as to whether they wish to be fully involved in drawing these up. All service users have access to the relevant health professionals. All service users are registered with a local surgery that has two GP’s; there is a routine weekly visit to the home. Service users may be visited at the home, or at the surgeries and have the choice of being seen by a male or female GP. An NHS chirpodist visits once every three months, training in foot care having been provided to staff when visiting in 2004. The home uses a domiciliary dental practice, with visits by a dentist and a dental hygienist to the home taking place on a six-monthly basis. Advice on oral care was given to staff on a recent visit in October 2005. There are no continence issues at present in the home. Written records of nutritional screening for service users are maintained. These include nutritional assessments and plans, monthly weight charts and records of food consumed. The home has detailed and comprehensive policies and procedures in place which cover privacy and confidentiality. The homes gives this a high profile and assists service users to complete questionnaires in relation to their privacy and dignity. These questionnaires fully explore the expectations of service users in relation to all aspects of their care. These questionnaires are used in the writing of service user plans and are reviewed annually. The review of these documents includes further discussion of service user’s rights and ensures service users are aware of the complaints procedure. The service users themselves complete a number of these questionnaires. These documents represent excellent examples of good practice and demonstrate a commitment to addressing service user’s privacy and dignity. Issues of privacy and dignity are discussed at service user’s meetings on a regular basis. The inspector received feedback from a number of service users which indicated that their privacy and dignity is being respected. There is a small, quiet upstairs lounge, or a small visitors room, where visitors can be received, or in the privacy of the service user’s own room. The home has not experienced any loss through death within the last year. Service users’ wishes regarding the eventuality of their infirmity or death are recorded on service users’ files, with the nearest relative being involved, wherever possible, in this process. The home has a policy and procedure on Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 14 ‘death and dying’ ; this was revised in January 2005. Training in the area of ‘death and dying’ has been provided to staff; the inspector discussed with the care manager, the need for training in bereavement and loss so as to assist staff in supporting service users when a death in the home, or family bereavement, occurs. This is made a recommendation. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: Not assessed. All these standards were well met at the last inspection. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 16 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): The home’s policies, procedures and practice evidence that service users are being protected from abuse and are living in a safe environment. All staff must, however, evidence their completion of statutory adult protection training. EVIDENCE: Standard 18 assessed. No complaints or adult protection concerns have arisen since the last inspection. Vulnerable Adult Procedures for the protection of adults are in place, together with the local authority Vulnerable Adults Policy, a copy of which is available in the home. A whistle blowing policy is also in place. Clear guidance is provided to staff about these policies with staff being made aware of the nature of various forms of abuse and the procedures for reporting any suspicions initially to senior staff. The care manager advised the inspector that there is discussion of adult abuse and adult protection procedures within service users’ meetings. The inspector spoke to a number of service users; this indicated that service users feel safe and well protected, there being no indication of any concerns. Since the last inspection all but one of the care staff have completed statutory adult protection training; this remains to be evidenced with the necessary Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 17 certification, which has not yet been received from Croydon’s training section. The new staff member is booked on to this training at the end of November 2005, but has completed internal training on abuse. The inspector discussed the need for the care manager to attend the ‘training for trainers’ course in adult protection which is run by Croydon; this would enable the care manager to cascade the statutory training to staff within the home. A recommendation applies. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 18 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): Service users are evidenced to live in a safe, well-maintained environment, with access to safe and comfortable facilities. Risk assessment of the home and individuals are in place for their protection. EVIDENCE: Standard 19 assessed. The home received a positive assessment across these standards at the last inspection, no requirements having been made. Service users are evidenced to live in a safe, well-maintained environment, with access to safe and comfortable facilities. Risk assessment of the home and individuals are in place for their protection. A fire risk assessment is in place. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 19 Since the last inspection the home has had a food hygiene inspection (on 27/7/05), an up-to-date inspection of the home’s hoists and passenger lift (on 24/10/05), and approved fire training has taken place. The inspector spoke to a number of service users. This indicated that service users feel safe living in the home. No incidents or accidents have been reported since the last inspection. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 20 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): The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s service users, and to ensure their safety. While the home has appropriate recruitment policy and practices in place, the protection of service users is placed at potential risk by the failure to have obtained an up-to-date criminal records check for new staff appointments. Staff are being provided with the necessary induction and training with which to competently perform their work duties EVIDENCE: Standards 28 to 30 were assessed. The inspector examined the staff duty rota. This evidenced that two carers are on duty throughout the day, with one waking, and one sleep- in at night. The inspector understands that an additional care staff member is employed to work during the busiest time of each day. A cleaner is on shift daily. The home does not use any agency staff. One new staff member has been recruited and has completed her induction programme. The home has generally thorough recruitment procedures in place. The inspector was, however, concerned to find that an up-to-date CRB and POVA check had not been completed for a recently recruited staff member. The registered person has been previously made aware that a new CRB check has to be undertaken where an employee has a CRB from a previous employer. The inspector Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 21 advised the care manager that until such time as the CRB and POVA checks have been completed, only supervised contact with service users is permissible. On the basis of the character references and documentation supplied, and evidence of the staff member’s performance and supervision to date, the inspector felt able to exercise discretion on this occasion. The care manager assured the inspector that correct procedures will be followed for any future staff appointments. The home organises a comprehensive induction programme that is in line with NTO (National Training Organisation) workforce training targets. This is ongoing over a period of six weeks, and comprises both training and observation. All staff undertake training in health and safety, fire safety, first aid, food hygiene, basic infection control, health and safety, manual handling, medication and adult abuse. The inspector spoke to a recently recruited staff member who has completed her induction programme. She expressed her satisfaction with the training and support being offered. Staff training files evidence training certificates and records of training undertaken. A system of staff supervision and appraisal is in place. Staff are appraised after the first six weeks and then on a six-monthly basis. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 22 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): Standards 32, 33, 35 and 38 were assessed. The home is being managed in the best interests of the home’s service users. The management approach is evidenced to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. The home has been developing its quality assurance processes, and is evidencing extensive consultation with service users, relatives and other parties. The quality assurance audit needs, however, to demonstrate the extent to which the home is meeting its aims and objectives. Service users’ financial interests are being appropriately safeguarded. The inspector is satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. EVIDENCE: Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 23 Standards The management approach in the running of the home was found to be an open and enabling one. The care manager and deputy manager, who were in charge on the day of inspection, were observed to interact well with both staff and service users and to assist in creating a positive and inclusive atmosphere. Service users expressed very positive views regarding the home and the way in which it is being run. Both staff and service users are encouraged to participate in the day-to-day running of the home, with staff and service user meetings being held on a regular basis. Service users are assisted and enabled to be as independent as possible and to exercise choice and control in their daily routines and activities. Staff members spoken to by the inspector indicated that they enjoy working at the home and are happy with the way in which the home is being managed. Service users, their families, and friends have been kept informed about previous planned CSCI inspections. Service users families are consulted about the conduct of the home and their views are regularly sought by means of the telephone, invitations to reviews, and for some, regular visits to the home, where relatives are able to meet and talk directly with care staff and the manager. At the request of service users ‘formal’ meetings are held on a monthly basis. Following the last inspection, two requirements were made regarding the home’s quality assurance processes. The care manager confirmed that progress has been made in developing a quality assurance audit based on the returns from questionnaires of service users, relatives, and other parties, and from other feedback. The inspector examined the tabulated layout of the audit results and identified a need for some further structuring, including development of the evaluation. As required, an annual development plan has been completed; this will need to be reviewed in the context of the quality assurance evaluation and should demonstrate a link with forward planning. Where possible, service users are enabled to retain control over their finances, with all but four service users being independent in managing their own finances. The home maintains records of service user’s monies with all transactions being accounted for with a receipt and a signature. There are secure facilities for the safekeeping of monies kept on behalf of service users. All services, equipment and facilities are maintained in a safe state to ensure the use and safety of the service user and staff. The home has completed all health and safety checks, these having been evidenced at the last inspection. Since then, the home has had a food hygiene inspection (on 27/7/05), an upRoselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 24 to-date inspection of the home’s hoists and passenger lift (on 24/10/05), and approved fire training has taken place. Risk assessments of the home have been completed. A requirement for all staff to receive accredited infection control training has been partially met. Six staff are currently undertaking a distance learning course with Croydon College, three other staff having previously completed an NCFE Certificate in infection control in June 2005. Training needs to be completed and extended to all remaining staff. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 25 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 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 3 X X 2 Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP18 Regulation 13 (6) Requirement Timescale for action 31/12/05 2 OP29 19.1a&b, Sch2, No 7 3 OP33 24 (1)(a) & (b) 4 OP38 24 (1) The registered person must evidence with certification that all staff have completed Croydon’s multi-disciplinary adult protection training. The registered person must 31/12/05 ensure that a new CRB and POVA check is completed prior to any new staff member commencing their employment at the home. A new CRB certificate for the recently recruited staff member must be obtained and evidenced. The registered person must 31/03/06 ensure that the results of the annual quality assurance audit are published and made available to current and prospective users, their representatives and other parties. A copy must be forwarded to the CSCI. The registered person must 31/03/06 ensure that all staff complete approved infection control training. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 27 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 OP22 OP11 OP18 Good Practice Recommendations The inspector recommends re-carpeting of the hall and stairway areas. The inspector recommends training in bereavement and loss so as to assist staff in supporting service users when a death in the home, or family bereavement, occurs. The inspector recommends that the care manager attends Croydon’s ‘training for trainers’ course in adult protection. Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Roselands DS0000025830.V264308.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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