Inspection on 24/02/06 for Rosemary Lodge

This inspection was carried out on 24th February 2006.

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

Rosemary Lodge 18/06/07

Rosemary Lodge 29/11/06

Rosemary Lodge 26/08/05

Rosemary Lodge 23/11/04

Rosemary Lodge 14/04/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Rosemary Lodge 9 The Drive Wimbledon London SW20 8TG Lead Inspector Janet Pitt Unannounced Inspection 24th February 2006 10:35 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 Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rosemary Lodge Address 9 The Drive Wimbledon London SW20 8TG 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 8946 6963 020 8296 0025 The Wimbledon Guild Mrs Margaret Sephton Care Home 44 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (22), Physical disability (25) Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can admit up to four named service users aged 60 years and over Date of last inspection Brief Description of the Service: Rosemary Lodge is situated in a residential area of Wimbledon, close to local bus routes. The home is within a twenty minute walk to Wimbledon Village. The home provides nursing and personal care for up to forty-seven older people. Rosemary Lodge is registered to provide care for up to four people with dementia and up to twenty-seven people who may have physical disabilities. The home is owned and managed by the Wimbledon Guild a registered charity. Accommodation is provided over three floors and includes a lounge, sun lounge, dining room, thirty-two single bedrooms and four shared bedrooms. Two passenger lifts serve each floor. Rosemary Lodge has access to a large level garden, which is mainly laid to lawn, with a paved area, pond, shrubs and trees. There is limited parking to the front of the home, however parking is also available on the street. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced on 24th February with one inspector and two inspectors visited the home on 2nd March 2006. The inspection lasted a total of six hours. Standards not assessed and requirements made at the previous inspection were assessed. During the course of the inspection the inspectors spoke with two relatives, three residents and three members of staff. Care documentation and staff files were examined. What the service does well: What has improved since the last inspection? What they could do better: 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. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 6 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 Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 7 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): EVIDENCE: None of these Standards were assessed but were met at the previous inspection. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 8 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, 10 and 11 Residents care plan detail care required, however the home must ensure that actual care given is recorded accurately. There must be a consistent approach to discussing residents’ religious needs and wishes. EVIDENCE: Residents care plans lead from the assessments and give clear instructions on how care needs should be met. However the daily records have not improved sufficiently to reflect the care given. Phrases such as; ‘All care given’ and ‘brought down for the day’ do not detail actual care given. There was some improvement in recording when specific incidents occurred such as a resident having a chest infection. One resident had complained of a headache and other care plans indicated that there was bruising, but no interventions or explanations for these conditions were noted. Lack of recording or interventions places residents at risk of not having their care needs evidenced as met or changes in their condition noted. Residents wishes on what to do in the event of death were not recorded consistently, which could lead to a lack of sensitivity and care. There has been some improvement on recording residents’ religious preferences, but it was noted on one care plan that there was a line in this Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 9 section. This does not provide relevant information. There was no evidence within the care plans of attendance at mass or church services. Involvement of residents or their representatives in care plans was inconsistent. One relative spoken with indicated that they had been involved in the care planning process and was satisfied with the care given. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 10 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: None of these Standards were assessed but were met at the previous inspection. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 11 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 and 18 Residents are not protected from harm, by the lack of recording of skin condition. Residents can be confident in the manager responding to concerns; staff should also have confidence in the management of the home. EVIDENCE: Residents confirmed that issues with complaints not being resolved at a local level, highlighted at the previous inspection have now been resolved. An anonymous complaint was received by the CSCI, in relation to bruising of residents, staffing, moving and handling training and communication with the manager. Residents who had experienced bruising were spoken with; they confirmed that the bruising was accidental. Staff must ensure that appropriate records are maintained, as care documentation and accident records did not reflect this. The manager confirmed that moving and handling training had been given and that there have been instances of staff not adhering to training. Appropriate action was taken to rectify this. Staff must make sure that they use correct procedures when assisting residents. As previously stated there are adequate numbers of staff to meet care needs. The manager was concerned that some staff felt unable to approach her directly and that the complainant contacted the CSCI in the first instance. The Protection of Vulnerable Adults policy needs to be updated to include contact details of the CSCI. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: None of these Standards were assessed but were met at the previous inspection. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 13 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 and 29 Residents are supported by appropriate numbers of staff. Recruitment process must include gathering of all available information on potential employees and relevant checks. Staff files did not reflect a consistent process. EVIDENCE: Residents are supported by appropriate numbers of staff; this was confirmed by examination of the duty rota. One member of staff raised concerns that nursing staff are interrupted during medication rounds to answer telephone calls. This must not occur unless there is an emergency, as residents are placed at risk of receiving incorrect medication. The policy relating to recruitment was seen to be satisfactory, however, recruitment processes do not protect residents from harm. Staff files examined did not contain all the information as required in the Schedules and there was no clear recruitment process. Two nursing staff files did not contain evidence of a check on current registration status. One staff file examined related to an employee who had previously worked at the home, but a new application form and references had not been obtained. This was discussed with the manager. The home must ensure that correct recruitment processes are followed whether an employee has worked at the home before or not, as employment history needs to be obtained. Identification checks were not noted to be contained within the files. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 14 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): 35 and 38 Residents can be assured that their personal allowances are handled appropriately. Health and safety issues must be addressed to ensure the safety of the residents. EVIDENCE: Residents’ personal allowances are maintained by the administration for the home. Records are held on computer. The health and safety of residents is not consistently maintained. There were no records of fire alarm tests or fire drills, although a member of staff indicated that they had occurred. Fire exits within the home were seen to be free from obstruction. The fire policy requires updating to include details of the address of Rosemary Lodge and not the Wimbledon Guild. Clinical waste was observed being disposed of without the yellow clinical bags being labelled to indicate their origin. Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 15 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 X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 16 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 OP7 Regulation 15 Sce 3(3)(k) 12 (4) (b) Requirement The registered person must ensure that daily records reflect actual care given. (previous timescale of 30/11/05 not met) The registered person must ensure that religious needs are noted on admission and addressed. (previous timescale of 30/11/05 not met) The registered person must ensure that residents’ wishes in the event of death are documented. (previous timescale of 30/11/05 not met) The registered person must ensure that moving and handling is undertaken appropriately in the home. The registered person must ensure that the skin condition of residents is recorded accurately. The registered person must ensure that the home’s Adult Protection Policy contains current details of the Regulatory Authority. The registered person must ensure that registered nurses are not interrupted whilst DS0000019118.V286357.R01.S.doc Timescale for action 30/05/06 2. OP10 30/05/06 3. OP11 12 (2) 30/05/06 4. OP16 22 (3) 30/05/06 5. 6. OP18 OP18 13 (4) (c) 13 (6) 30/05/06 30/05/06 7. OP27 13 (4) (c) 30/05/06 Rosemary Lodge Version 5.1 Page 17 8. OP29 19 & Sch 2 9. OP29 19 10. OP38 23 (4) 11. OP38 16 (2) (k) undertaking the medicine round. The registered person must ensure that staff files contain information as required by the Schedules and appropriate checks are carried out on staff. The registered person must ensure all staff undergo a thorough recruitment process prior to being employed. The registered person must ensure that fire drills and alarm tests are recorded when carried out. The fire policy must reflect the correct address of the home. The registered person must ensure that clinical waste is labelled appropriately prior to being disposed of. 30/05/06 30/05/06 30/05/06 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Rosemary Lodge DS0000019118.V286357.R01.S.doc Version 5.1 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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