Inspection on 30/09/06 for Rosemary Lodge

This inspection was carried out on 30th September 2006.

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

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

Other inspections for this house

Rosemary Lodge 05/06/08

Rosemary Lodge 07/09/07

Rosemary Lodge 03/05/07

Rosemary Lodge 05/05/06

Rosemary Lodge 08/09/05

Rosemary Lodge 08/04/05

Rosemary Lodge 21/12/04

Rosemary Lodge 27/07/04

Rosemary Lodge 14/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Rosemary Lodge 154 Alcester Road South Kings Heath Birmingham West Midlands B14 6AA Lead Inspector Zeta Joseph Key Unannounced Inspection 30th November 2006 09:30 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 Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemary Lodge Address 154 Alcester Road South Kings Heath Birmingham West Midlands B14 6AA 0121 43 1166 0121 442 6454 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) Mr S.V. Chundoo Elizabeth Campbell Mrs Rajwantee Chundoo Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home adheres to a laundry policy which ensures that soiled laundry is not transported through the dining area when meals are served or consumed. 5th May 2006 Date of last inspection Brief Description of the Service: Rosemary Lodge is situated on the Alcester Road, Kings Heath; it is a short distance away from the main Kings Heath shopping centre where there is a good range of local facilities. Another smaller local shopping centre is in the opposite direction towards The Maypole. The home was originally two large Victorian houses, has retained many of its original features and is set back behind a parking area for up to 5 cars. Trees and shrubs that have been well maintained surround this area. The main entrance to the home is via some steps up to the front door; this access is unsuitable for wheelchair users and is currently being used as access for the building work that is being carried out. There is another front door, located to the front of the property where people with mobility difficulties can access the home at ground level where access is gained into the dinning area. The home has a passenger lift to where the first floor bedrooms can be accessed; the second floor is office space. There is a garden to the rear of the property. The home caters for up to thirty older people. The bedrooms vary in size and all are decorated in individual colours. There is a large dining/sitting room, a smaller lounge, a ‘Victorian’ themed sitting room, a large quiet sitting room and a conservatory. Each bedroom is supplied with a copy of the Service User Guide, but this document is generic and not specific for individual residents. There is no information. At the time of the fieldwork inspection, extensive building work is being undertaken to build a new conservatory and additional bathing and toileting facilities for residents. Parking is restricted because of the skip outside the property. There is no egress from the home into the rear garden and when the builders are at the home part of the ground floor is inaccessible to residents. There are signs throughout the home to warn people about the building work. There is a risk assessment for the parts of the home that residents and visitors cannot access due to the building work. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 5 There is no notice board for residents and visitors to read information such as progress of the building work and how this would benefit residents; neither is there a copy of inspection reports for residents and visitors to access. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork inspection was undertaken by two inspectors and was carried out over a period of five and a half hours; the deputy manager who was in charge of the shift because the registered manager was on annual leave provided assistance. There were twenty-one residents living at the home, and two of these residents were in hospital. Information was gathered from speaking with three residents and staff. Care, health and safety and the arrangements for medication were inspected. Staff and residents personnel files were checked and staff were observed whilst performing their duties. It was not always possible to hold meaningful conversations with some residents because they had a form of dementia. Some post fieldwork was carried out and this concerned a podiatrist who had raised concerns about the care of resident’s feet and the Responsible Individual is investigating this. At the conclusion of the fieldwork inspection, verbal feedback was given to the Responsible Individual and the owner of the business. Immediate Requirements were made and these related to care staff undertaking kitchen duties or assisting the cook without the basic Food Hygiene training, and that untrained for only trained and competent staff to undertake the assessing and completing of resident’s risk and manual handling assessments. What the service does well: The service ensures that a plan of care and Placement Authority is obtained prior to the potential resident moving in. Without this documentation the care service could not start. The Deputy Manager is responsible and trained to undertake medicine management. The medication system that is in place ensures that the right medication is administered to the right resident at the right time and records reflect practice. Residents who share bedrooms have been provided with screens to ensure their privacy and dignity. The laundry and kitchen rooms were visited. These were found to be tidy and the laundry organised satisfactorily. The kitchen is accessed by a coded door lock to protect residents from access and harm. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 7 The Responsible Individual investigates concerns/complaints that are brought to her attention. The hot water outlets have thermostatic valves fitted to control the temperature of hot water. What has improved since the last inspection? What they could do better: The requirements from the last inspection have not been addressed, and an action plan has not been provided to the Commission. This means that resident’s needs are not always met in the way they want or by individualised assessment. The Statement of Purpose and Service User Guide must include information about how refurbishments improve service delivery for residents. This requirement remains unmet since 16th June 2006. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 8 Residents are issued with a contract detailing the terms of residency. It was noted that this document does not include the fee rate or details of the room occupied. There must be sufficient trained and competent staff (including the manager) working in the care home who are trained in dementia and care planning so that residents care needs are fully met. This requirement remains unmet since 30th August 2004. There must be clear documentation maintained of pre-admission/trial visits before the decision is made for the potential resident to stay permanently. This requirement remains unmet since 1st August 2006. Although the home ensures placement documents are obtained from Social Care and Health, Inspectors were unable to audit these due to the disarray of residents’ paperwork in the registered managers office. Residents individual care plans must be developed from the initial care plan provided by the Social Care and Health Department. These must be available for care staff to refer to and include details of resident’s personal preferences for daily routines, personal care, life history and background. Any behaviours assessed as difficult to manage need to include the possible triggers and type of behaviour displayed. Care plans for short term illnesses such as urinary or chest infections must be developed so that staff can refer to them. Advice and guidance from health care practitioners must be recorded in care plans, reflected in work practice and demonstrated within continuity of service delivery so that residents’ health care needs are met. Inspectors were unable to audit these due to the disarray of residents’ paperwork in the registered managers office. This requirement remains unmet since 30th August 2004. Residents’ must be enabled to access community health care professional so that they benefit from screening and professional advice especially when discharged from hospital. Residents’ records must evidence this and Inspectors were unable to audit these due to the disarray of residents’ paperwork in the registered managers office. This requirement is unmet since 8th April 2005. There is no evidence to show whether the home provides varied social activities and outings that meet the expectations of residents, nor how they are enabled to exercise choices over their daily routines. There is no information available to assess how residents’ are empowered to exercise their choices and preferences within the home. For example shared rooms and meal choices. A requirement relating to shared rooms remains unmet since 25th April 2005. Inspectors were unable to audit information due to the disarray of residents’ paperwork in the registered managers office. This means that resident’s ability to choose remains unmet. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 9 A robust infection control audit must be implemented so that residents benefit from a home that is hygienic and clean. There was an odour of urine near to bedroom 26 on the ground floor. Inspectors examined an audit undertaken by the registered manager in April 2006, this related to a ‘dirty kitchen’ and ‘food outdated’. Due to the disarray of paperwork in the registered managers office the home could not demonstrate good practice in this area. The requirement relating to robust infection control remains unmet since 4th August 2004. Information about good practice in nutrition for people with special diets, eating difficulties and poor appetites must be included in resident’s care plans so that residents’ nutritional needs are met. Inspectors were unable to audit these due to the disarray of residents’ paperwork in the registered managers office. Requirements relating to this remain unmet since 31st August 2004. The qualifications of the kitchen assistant could not be audited due to the disarray of personnel files in the registered managers office. This requirement remains unmet since 31st May 2005. Observations confirmed that staffing numbers remain unmet because shortfalls in the kitchen were made up from the complement of five care staff on duty to care for nineteen residents at the time of the key inspection. This means that unqualified staff were working in the kitchen, leaving insufficient staff to cover domestic and care staff duties. Adequate and consistent staffing levels must be maintained so that continuity of nutritious, well balanced and wholesome meals are always promoted and provided for residents. There is no menu on display in large print for the convenience of those persons who are visually impaired. There is a four week menu in the kitchen that provides residents with some choices, because on certain weeks there is one choice for lunch and the desert at teatime. There is no indication of special dietary choices for residents who need this. This means that residents’ dietary needs are not being met. There is one dinning room and meals are served from trolleys (not heated trolleys). As residents care plan information was in disarray in the manager’s office, it was not possible to establish the resident who required soft diets or pureed meals. Residents were not always conversing and using the opportunity to enjoy the meal. The Registered Manager is inconsistent in managing concerns/complaints and the Responsible Individual is not always informed about complaints/concerns. The Commission has not received any complaints about the home since the last inspection. The office was in disarray and it was not possible to audit any concerns or complaints made to the home. There is an adult protection procedure, but due to the disarray in the manager’s office it was not possible to even audit whether staff have been provided with robust induction training in adult protection before being placed with vulnerable residents and this does not safeguard them. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 10 A robust infection control audit must be implemented so that residents benefit from a home that is hygienic and clean. There was an odour of urine near to bedroom 26 on the ground floor. Where residents have access to hot water these are not tested regularly so that residents are protected from the risk of scalds. Staffing levels are not always maintained in sufficient numbers to ensure that resident’s needs are being met. Staffing numbers remains poor because the shortfalls in the kitchen was from the complement of five care staff on duty whose role is to care for nineteen residents at the time of the key inspection. This means that insufficient staff are left to cover domestic and care staff duties and this does not safeguard residents. Staff rotas were available for February to April 2006 with recordings of five staff on early, three staff on late and two or three staff on at night, there was no current definitive working rota available in the disarray of the manager’s office, and this does not safeguard residents. Staff recruitment records must comply with Schedule 2 of the above regulations and a more robust recruitment process is implemented to protect residents. Two references must by pursued, one from the previous employer and all gaps in employment history must be explored with comprehensive records maintained. The Manager recruited a member of staff with convictions on their Criminal Record and no risk assessment was undertaken. Recruitment practices are very poor and resident’s safety is not paramount. The disarray in the manager’s office did not make it possible to audit any mandatory or specific training information, and untrained staff do not safeguard residents. A training matrix must be developed, reviewed and updated. The Responsible Person when asked confirmed that the Registered Manager is not trained to undertake supervision and appraisal yet this is part of her job description and job role. Neither staff nor residents benefit from an untrained/unqualified manager who fails to implement the minimum standards relating to supervision. Requirements relating to this remain unmet since 30th August 2004. The manager’s supervision and performance management records were not available. The registered manager has been asked by the owner to manage the home by implementing unmet requirements from the last inspection report so that the home strives to make continual improvements for the good of residents. The Registered Manager has not completed the Registered Managers Award/ National Vocational Qualification in Care at Level 4 and this is an unmet requirement. This qualification will provide her with knowledge and skills to Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 11 provide leadership for the residents she is responsible for. This requirement remains unmet since 30th May 2006. The Registered Person/Manager must manage the home with sufficient skill and competence so that the health and safety of residents is key to the success of service delivery. It was not possible to audit whether the arrangements for the safekeeping and financial transactions of residents personal monies are robust because of the disarray in the managers office. This does not protect residents from being financially abused. After this key inspection, the Commission received concerns about a private health care professional not being paid for the work done with residents. An effective quality assurance and monitoring system has not been implemented to monitor the quality of service provided. This means that residents have not benefited from quality care. This requirement remains unmet since 1st December 2004. It was not possible to audit accident records or fire alarm, emergency lighting, fire drills, or maintenance of equipment records to check whether these are fit for purpose because of the disarray in the managers’ office. This means that residents and others are not protected from the risk of injury. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 12 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 DS0000017019.V321612.R01.S.doc Version 5.2 Page 13 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Responsible Person confirmed that a copy of the Service User Guide is provided to all residents. Residents’ contracts or terms and conditions of residency must comply with the minimum standards and must be signed by the resident. EVIDENCE: The Service User Guide forms the contractual/statement of terms and conditions within the home and potential residents are provided with a copy of this document; this means that they have basic information about the home before the start of residency. Examination of the Service User Guide (March 2006) shows that the description of the physical environment does not match with the current circumstances of the home. For example observations during the tour of the Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 14 building there is only one assisted bathroom for nineteen residents and this is wholly inadequate and the service provides very poor personal care facilities to meet residents personal care needs. There is currently, insufficient and inadequate bathing facilities to meet the needs of the twenty nine residents the home is registered for. A requirement relating to poor bathing and washing facilities have been unmet since December 2004. There is extensive work ongoing to the rear of the property and there is no information about how this will benefit and meet the needs of people living at the home; this has been an unmet requirement since September 2004. The Service User Guide (Sections 5 and 9) describes qualified staff working at the home, this was not as found at this key inspection because there were staff including evidence of the Registered Manager working in the kitchen without basic Food and Hygiene qualifications. A requirement relating to this has been unmet since May 2006. The staffing numbers referred to in this document relates to previous requirements made by Inspectors and the staffing numbers referred to remains unmet because of shortfalls in the kitchen as this was made up from the complement of five care staff on duty to care for nineteen residents at the time of the key inspection. Section nine of the Service User Guide describes ‘choice of 2 meals…’, and examination of week 2 menu shows that on Tuesday there is one option for lunch and tea. This document describes ’special diets’ and for one diabetic resident there is no indication of specific meals for this person. This means for residents with special dietary needs currently living at the home, their nutritional needs are not being met. Section seventeen of the Service User Guide describes ‘benefit advice’, when the Responsible Person was asked about his experience of providing such advice, he was unable to confirm his knowledge of benefits. This means that the home provides residents with information about some services that are not always offered by trained staff and this does not protect residents. Residents are issued with a contract detailing the terms of residency. It was noted that this document fails to include the fee rate or details of the room occupied. The Social Care and Health Department undertake a care assessment of people prior to them being provided with a residential placement; without this assessment residents would not receive a care service. There were no new residents admitted since the key inspection in May 2006 where documentation relating to pre-admission was incomplete and not robust enough to indicate how the home will meet needs. Records relating to preadmission are being updated for inclusion within the newly implemented Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 15 multidisciplinary care planning documentation. The current arrangements for pre-admission is very basic, this document serves to ensure that the home is able to meet the respective persons needs at admission. There is no information about re-assessment if a resident is admitted to hospital and if the home is able to meet those needs. The home does not cater for people assessed and referred solely for intermediate care. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 16 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Resident’s health care is not always evidenced in the care planning process. The management of medicines is good and this safeguards residents. Residents sharing a room must be given an informed choice of a suitable single room and records must be maintained about this. Observations of staff indicated that resident’s privacy and dignity are being maintained. EVIDENCE: The Responsible Individual is a trained assessor and is implementing a multidisciplinary care planning tool for all residents, this is so that all aspects of the residents’ health care is discussed, assessed and managed. This is ongoing for all residents and they will benefit because information is more detailed and this ensures all aspects of care delivery will be met. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 17 Residents individual care plans must be developed from the initial care plan provided by the Social Care and Health Department. These must be available for care staff to refer to and include details of resident’s personal preferences for daily routines, personal care, life history and background. Any behaviours assessed as difficult to manage need to include the possible triggers and type of behaviour displayed. Care plans for short term illnesses such as urinary or chest infections must be developed so that staff can refer to them. The registered manager is not a trained assessor and there is no evidence to show the ongoing involvement of individualised care planning or nutritional screening for residents who require a specific diet so that their specific needs are met and included on the care plan. Information about good practice in for people with special diets, eating difficulties, poor appetites must be included in the plans so that residents’ nutritional needs are met. This does not value or respect residents. At the last key inspection, the Registered Manager had provided residents with plastic covers for their mattresses regardless of whether the resident required it. This does not respect or value the resident and to date, the manager has not confirmed with the Commission reasons for doing this. Residents’ must be enabled to access community health care professional so that they benefit from professional assessments and advice especially when discharged from hospital. Residents’ records must evidence this. Records examined in the manager’s office were in disarray, not up to date and little to no individual care assessments for residents and this does not safeguard them. Advice and guidance from health care practitioners must be recorded in care plans, reflected in work practice and demonstrated within continuity of service delivery so that residents’ health care needs are met. Residents’ medical records and charts are well managed by staff trained to undertake the administration of medication. The medication trolley is bolted and secured to a solid wall. The medication system that is in place ensures there are current prescriptions on file and there are no gaps on the medication records that the right medication is administered to the right resident at the right time and records reflect practice and residents are protected. There are no residents who self medicate. At the last key inspection the Registered Manager was not able to demonstrate how residents choices were promoted for example when an opportunity arose for people to move out of a shared room, especially when a resident without dementia was sharing a room with a resident. The Inspector raised concerns about residents’ compatibility when sharing bedroom facilities. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 18 Residents who share bedrooms have been provided with screen to ensure their privacy and dignity. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 19 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no evidence to show whether the home provides varied social activities and outings that meet the expectations of residents, nor how they are enabled to exercise choices over their daily routines. The Registered Provider must ensure that residents are offered appealing choices of meals prepared by qualified staff. EVIDENCE: Examination of week 2 menu shows that on Tuesday there is one option for lunch and tea. There is a diary in the kitchen and this includes records of resident’s meal preferences for October 2006; however, since November 2006 there are no meal preferences recorded and the care staff working in the kitchen were preparing a meal without confirming residents choices and preferences. There is a separate daily kitchen management record of the meal served to residents and this was not the same as the meals on offer on the menu. This record also describes ’special diets’, and for one diabetic service Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 20 user there is no indication of specific meals for them. This means for residents with special dietary needs, or eating/swallowing problems, currently living at the home, their nutritional needs are not being met. There is one dinning room and meals are served from trolleys (not heated trolleys). As residents care plan information was in disarray in the manager’s office, it was not possible to establish the resident who required soft diets or pureed meals. Residents were not always conversing and using the opportunity to enjoy the meal. The kitchen management records includes kitchen cleaning schedules, safety in the kitchen, managing problems in the kitchen and these records should be signed by the person undertaking these tasks. These records are not always completed or signed despite the registered manager working in the kitchen and having daily access to these records. There is no evidence to show whether the home provides varied social activities and outings that meet the expectations of residents, nor how staff encourages and promotes individuality and independence. There are no records maintained of those residents who are interested in participating in activities so that staff assist in identifying individual preferences. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 21 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents and relatives are not confident that their views and complaints will be dealt with effectively. Lack of staff training in adult protection fails to protect residents from the risk of abuse. EVIDENCE: There is a complaints book and a numerical log is kept of these so that the complaint is linked back to the complainant. The Commission has not received any complaints about the home since the last inspection. The office was in disarray and it was not possible to audit any complaints made to the home. Production of the complaints procedure in large print and/or audio cassette will assist residents who are visually impaired. There is an adult protection procedure, but due to the disarray in the manager’s office it was not possible to even audit whether staff have been provided with robust induction training in adult protection before being provided with comprehensive training. The home must ensure that staff are provided with the knowledge and skills to act appropriately in protecting residents from the risk of abuse. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 22 Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents live in a warm home that is undergoing building work to improve the toileting, bathing and hairdressing facilities; the conservatory is being extended. EVIDENCE: Residents do not have a choice of bath or shower to suit their individual preferences because the ground floor bathing facilities is the only suitable and appropriate one available. The bathing facility is spacious enough for people who have restricted mobility, but residents occupying the upper floors will have to travel further in order to access it. Due to the building work that is being undertaken only one of the two ground floor lounges are available for residents to sit together. The Responsible Person provided the Commission with a copy Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 24 of the risk assessment for the building work so the safety of residents is paramount. Bedrooms are of single and shared double occupancy, are individually and naturally ventilated, and windows are fitted with restrictors to prevent accidents occurring. There was an odour of urine near to bedroom 26 on the ground floor. The Inspector looked in the majority of bedrooms and spoke with three residents who had their own door key to promote their preferences regarding their own privacy and dignity. The laundry and kitchen rooms were visited. These were found to be tidy and the laundry organised satisfactorily. The kitchen is accessed by a coded door lock to protect residents from access and harm. There is a cleaning schedule available and this is used to ensure the building is cleaned; however, the schedule is not based on the robust infection control format supplied by the Health Protection Nurse in January 2004 so that the leaning would be done more robustly and residents would be protected from the risk of cross infection. Inspectors examined a kitchen audit undertaken by the registered manager in April 2006, this related to a ‘dirty kitchen’ and ‘food outdated’. Due to the disarray of paperwork in the registered managers office the home could not demonstrate good practice in this area of management. The hot water outlets have thermostatic valves fitted to control the temperature of hot water. However, where residents have access to hot water these are not tested regularly so that residents are protected from the risk of scalds. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are not always maintained in sufficient numbers to ensure that resident’s needs are being met. Recruitment practices are very poor and this does not protect residents. A training matrix must be developed, reviewed and updated. EVIDENCE: Staffing numbers remains unmet because shortfalls in the kitchen were made up from the complement of five care staff on duty whose role is to care for nineteen residents at the time of the key inspection. This means that insufficient staff are left to cover domestic and care staff duties and this does no safeguard residents. Staff rotas were available for February to April 2006 inclusive with recordings of five staff on early, three staff on late and two or three staff on at night, there was no definitive working rota available in the disarray of the manager’s office, and residents are not safeguarded. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 26 The permanent cook is qualified with a Food and Hygiene Certificate dated 31st March 2005; the Responsible Individual said they would provide the cook with advanced training. The qualifications of the kitchen assistant could not be audited due to the disarray of personnel files in the registered managers office. Staff recruitment records must comply with Schedule 2 of the above regulations and a more robust recruitment process is implemented to protect residents. Two references must by pursued, one from the previous employer and all gaps in employment history must be explored with comprehensive records maintained. The Manager recruited a member of staff with convictions on their Criminal Record and no risk assessment was undertaken; this means that resident’s safety is not paramount. A staff-training folder was examined; there is no evidence to show where staff undergo a more comprehensive formal induction based on Skills for Care standards that will provide staff with the skills to perform their roles appropriately. There was no evidence of any staff training since 12th November 2005 when ‘in house’ training on medication took place and fire training on 12th May 2006. The disarray in the manager’s office did not make it possible to audit any mandatory or specific training information, and untrained staff do not safeguard residents. The Responsible Person, when asked confirmed that staff including the Registered Manager is not provided with accredited mandatory training in safe manual handling assessments and techniques, including wheelchair training. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Registered Manager has not demonstrated that the home is managed with robustness and resident’s health and welfare are not protected by safe working practices. EVIDENCE: The Registered Person and Manager shall, having regard to the health and safety of residents, manage the home with sufficient skill and competence and that all outstanding requirements from previous inspections are acknowledged and an action plan submitted to the Commission. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 28 The Registered Manager must provide evidence to the Commission of qualification to NVQ Level 4 in Management or equivalent. An extension to the date required has been re negotiated with the Manager as 31/12/05. The Registered Person shall ensure the Manager manages the home in an open and transparent manner and communicates clear direction and leadership to staff so that residents are provided with service in line with the quality assurance protocols for the home. An effective quality assurance and monitoring system has not been implemented to monitor the quality of service provided. This means that residents have not benefited from quality care. Supervision processes includes employment policies adopted by the home and that induction and training arrangements are recorded and reviewed within supervision. A staff supervision folder was examined and the supervision planner states that the registered manager supervised five staff in April 2006, no other dates was recorded. Formal supervision of care staff does not take place a minimum of six times per year. The Responsible Person when asked confirmed that the Registered Manager is not trained to undertake supervision and appraisal yet this is part of her job description and job role. Neither staff nor residents benefit from an untrained/unqualified manager who fails to implement the minimum standards relating to supervision and not making continuous improvements for the benefit of residents. The home owner has been supervising and performance managing the registered manager; however records were not available to prove that she is being supported by the current management structure. The registered manager has been asked by the owner to manage the home by implementing unmet requirements from the last inspection report so that the home strives to make continual improvements for the good of residents. The responsible person purchased a quality assurance system prior to the last inspection. The manager ignored requests from the responsible person/owner to implement for example new care plan assessments. The owner was seen bringing in some resident’s care plans during this key inspection. This does not demonstrate that residents were involved in their own care planning. Fridge and freezer temperatures were audited and from October 2006, there is no indication of what the normal fridge and freezer settings should be, nor the acceptable range. Most recordings were not recorded and it is clear from these readings that there are serious concerns that must be managed. The actual filing of these records is mis-managed and recordings for different fridges are made on the same documentation. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 29 It was not possible to audit whether the arrangements for the safekeeping and financial transactions of residents personal monies are robust because of the disarray in the managers office. This does not protect residents from being financially abused. After this key inspection the Commission received concerns about a private health care professional not being paid for the work done with residents. The manager’s familiarity with the quality system is at best poor and the disarray in her office evidences the quality of her work. The manager was absent during this key inspection and was therefore unavailable to account for poor management. It was not possible to audit accident records or fire alarm, emergency lighting, fire drills, or maintenance of equipment records to check whether these are fit for purpose because of the disarray in the managers’ office. This means that residents and others are not protected from the risk of injury. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 30 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 2 2 3 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 1 1 2 1 2 2 1 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X 1 1 1 1 Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 31 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 OP1 Regulation 4(c)5(c) Requirement The Registered Person shall ensure the Statement of Purpose and Service Use Guide includes how refurbishments have improved service delivery. THIS REQUIREMENT REMAINS UNMET SINCE 01/12/04. Each resident must be provided with a copy of the Service User Guide which outlines the terms and conditions of residency. The Registered Person is required to ensure there are trained and competent staff working in the care home that are trained in dementia and care planning so that residents’ needs are met. THIS REQUIREMENT REMAINS UNMET SINCE 30/08/04. There must be clear documentation maintained of pre-admission/trial visits before the decision is made to stay at the home on a permanent basis. THIS REQUIREMENT REMAINS UNMET SINCE 01/08/06 DS0000017019.V321612.R01.S.doc Timescale for action 01/03/07 2. OP2 5© 01/03/07 3. OP4 17(1) 01/05/07 4. OP5 17(1) 01/03/07 Rosemary Lodge Version 5.2 Page 32 5. OP7 13(1)(b) 6. OP8 7. OP8 8. OP9 Residents individual care plans must be developed from the initial care plan provided by the Social Care and Health Department. These must include: 1. Details of resident’s personal preferences for daily routines and personal hygiene. 2. Difficult to manage behaviour need to include the possible triggers and type of behaviour displayed. 3. Record the resident’s life history and background. 4. Develop care plans for short term illnesses such as urinary or chest infections. 13(1)(b) Advice and guidance must be obtained from health care professionals and this must be recorded in care plans, reflected in work practice and demonstrated within service delivery. THIS REQUIREMENT REMAINS UNMET SINCE 08/04/05 13(1)(b) Residents must be enabled to access community health care professionals so that they benefit from screening especially when discharged from hospital. Residents’ records must evidence this. THIS REQUIREMENT REMAINS UNMET SINCE 08/04/05 18(1)(a)(c The Registered Person shall ) ensure the Registered Manager completes an accredited medication training course; a certificate of completion must be available for inspection. THIS REQUIREMENT REMAINS UNMET SINCE 30/11/05. 01/03/07 01/03/07 01/03/07 01/03/07 Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 33 9. OP10 12(4) 10. OP12 16(2)(m) 11. OP14 12(2) 12. OP15 13(1)(b) 16(2)(i) The respect and dignity of residents must be paramount when personal care is being undertaken, and when meals are being provided so that their wishes and feelings are taken into account. The programme of residents’ activities and outings must meet their expectations and promote their individuality. The Registered Manager shall demonstrate how residents’ are empowered to exercise choices and preferences within the home. E.g. shared rooms and meal choices. THIS REQUIREMENT REMAINS UNMET SINCE 25/04/05 Residents must be offered appropriately varied, appealing and nutritious meals and snacks; especially so that residents with assessed specific dietary needs are fully met. Suitable alternatives must be available. THIS REQUIREMENT REMAINS UNMET SINCE 31/08/04. The qualifications care assistants working in the kitchen must be evidenced and the cook provided with enhanced training. THIS REQUIREMENT REMAINS UNMET SINCE 31/05/06 Complaints and concerns must be dealt with promptly and efficiently and information about these must be available. The Registered Manager must ensure that all care staff are provided with training in Adult Protection including Birmingham’s Multi Agency Guidelines so that they possess the knowledge and skills to respond appropriately in allegations of suspected abuse. DS0000017019.V321612.R01.S.doc 01/03/07 01/03/07 01/03/07 01/03/07 13. OP15 16(2)(i) 01/03/07 14. OP16 22 08/03/07 15. OP18 13(6) 08/03/07 Rosemary Lodge Version 5.2 Page 34 16. OP19 23(2)(b) 17. OP20 23(2)(i) 18. OP21 23(2)(n) The Registered Person must ensure the home is kept in a good state of repair as per the schedule provided to the Commission. THIS REQUIREMENT REMAINS UNMET SINCE 31/08/05 The Registered Person must ensure that residents have access to all communal areas so that resident’s needs is catered for. The Registered Person must ensure that a review of washing and bathing facilities is carried out including appropriate plans to meet the assessed needs of residents’. The plans, when submitted to the Commission must have time scales indicating when the work is to be carried out. THIS REQUIREMENT REMAINS UNMET SINCE 01/12/04. The Registered Person must provide evidence that the recommended adaptations to the home meets residents’ needs. THIS REQUIREMENT REMAINS UNMET SINCE 30/09/04. Residents must be provided with an informed choice to share their private bedroom accommodation, and must be given the opportunity to move to another room when one becomes available; records must be maintained of this. THIS REQUIREMENT S REMAINS UNMET SINCE 30/09/04. The Registered Person shall ensure each resident is not provided with a plastic mattress covering unless an assessment states to the contrary. Records must be maintained and detailed DS0000017019.V321612.R01.S.doc 31/03/07 31/03/07 01/06/07 19. OP22 23(2)(n) 31/03/07 20. OP23 23(2) 31/03/07 21. OP24 14(2) 01/03/07 Rosemary Lodge Version 5.2 Page 35 22. OP25 13(4) 23 23. OP26 16(2)(k) 24. OP27 18 25. OP28 18(1) in the care plan. THIS REQUIREMENT REMAINS UNMET SINCE 30/05/06. The Registered Person shall ensure that the building extension includes lighting, heating, water supply and ventilation that meet the relevant environmental health and safety requirements and the needs of individual residents. THIS REQUIREMENT REMAINS UNMET SINCE 30/09/04 AND IS LINKED TO STANDARD 22. The premises must be clean, hygienic and free from offensive odours. A cleaning audit of the home must be conducted using the format provided by the Health Protection Nurse. THIS REQUIREMENT REMAINS UNMET SINCE 30/05/06 Domestic, kitchen and care staff must be employed in sufficient numbers to ensure that resident’s needs are fully met and that the home is maintained in a clean and hygienic state, free from dirt and unpleasant odours. THIS REQUIREMENT REMAINS UNMET SINCE 30/06/06 The Registered Person shall ensure staff induction and mandatory training complies with Skills for Care (previously TOPSS) foundation standards. THIS REQUIREMENT REMAINS UNMET SINCE 01/12/04. The Registered Person must ensure that staff recruitment records comply with Schedule 2 of the above regulations and a more robust recruitment process is implemented to protect residents. Two references must by pursued, one from the DS0000017019.V321612.R01.S.doc 31/03/07 01/03/07 01/03/07 01/03/07 26. OP29 19Sch 2 01/03/07 Rosemary Lodge Version 5.2 Page 36 previous employer and all gaps in employment history must be explored. Staff with criminal convictions must be risk assessed with the Responsible Individual so that an agreement is made regarding extending the probationary period. Comprehensive records must be maintained so that residents, staff and visitor are protected. THIS REQUIREMENT REMAINS UNMET SINCE 01/12/04. 27. OP30 19(1)10(3 ) The Registered Person shall ensure all staff including the Manager are provided with accredited mandatory training in safe manual handling techniques, including wheelchair training. Training must be reviewed and updated annually. THIS REQUIREMENT REMAINS UNMET SINCE 01/12/04. 01/03/07 28. OP31 10(1) The Registered Person and 31/03/07 Manager shall, having regard to the health and safety of residents, manage the home with sufficient skill and competence and that all outstanding requirements from previous inspections are acknowledged and an action plan submitted to the Commission. THIS REQUIREMENT REMAINS UNMET SINCE 27/07/04. The Registered Manager must provide evidence to the Commission of qualification to NVQ Level 4 in Management or equivalent. An extension to the date required has been re negotiated with the Manager as 31/12/05. THIS REQUIREMENT REMAINS UNMET SINCE 31/12/05. DS0000017019.V321612.R01.S.doc 29. OP31 18(1) 01/03/07 Rosemary Lodge Version 5.2 Page 37 30. OP32 18 31. OP33 35 32. OP35 16(2)(l) 33. OP36 18©(i) 34. OP37 17(1) 35. OP38 18(1) The Registered Person shall ensure the Manager manages the home in an open and transparent manner and communicates clear direction and leadership to staff so that residents are provided with service in line with the quality assurance protocols for the home. THIS REQUIREMENT REMAINS UNMET SINCE 31/11/05. An effective quality assurance and quality monitoring system must be implemented that meets the minimum standards. Systems and processes must be in place to monitor the quality of services being provided so that residents benefit. THIS REQUIREMNET REMAINS UNMET SINCE 01/12/04 There must be a robust financial management system in place that ensures that when private care is provided e.g. chiropody services; that the payment of these services is managed satisfactorily and residents are safeguarded. Formal supervision of all staff must take place six times per year with records maintained in individual staff files. THIS REQUIREMENT REMAINS UNMET SINCE 01/12/06. Records required for the protection of residents and for the effective and efficient running of the business must be maintained in a good order, up to date, accurate. The disarray in the manager office must be rectified without delay. THIS REQUIREMENT REMAINS UNMET SINCE 01/12/06. The Registered Person must DS0000017019.V321612.R01.S.doc 01/03/07 01/03/07 31/03/07 31/03/07 01/03/07 01/03/07 Page 38 Rosemary Lodge Version 5.2 ensure that supervision and performance management processes includes employment policies adopted by the home and that induction and training arrangements are recorded and reviewed within supervision. Records must be available for inspection. THIS REQUIREMENT REMAINS OUTSTANDING SINCE 30/11/05. 36. OP38 18(1) The Responsible Individual must ensure that the Registered Managers performance management supervisory records are available so that it is demonstrated that the support and guidance provided is robust enough to ensure that the home is managed so that the needs of residents is fully met. Every effort must be made to ensure that when people are carrying out external work to the home that they adhere to safety regulations and wear protective equipment. THIS REQUIREMENT REMAINS UNMET SINCE 28/7/04. Fridge and freezer temperatures must be maintained. THIS REQUIREMENT REMAINS UNMET SINCE 20/05/06. Ventilation, heating, lighting and water maintenance records must be available so that resident’s health care is paramount. Equipment provided at the home for use by residents or staff must be maintained and in good working order. Egg hoists; lift electrical appliances so that resident’s health care is paramount. 01/03/07 37. OP38 16(1) 01/03/07 38. OP38 16(2(g) 01/03/07 39. OP38 23(2)(p) 31/03/07 40. OP38 23(2)© 31/03/07 Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 39 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations That access to the premises is made clear by signage to one of the front doors. Rosemary Lodge DS0000017019.V321612.R01.S.doc Version 5.2 Page 40 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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