Inspection on 05/05/06 for Rosemary Lodge

This inspection was carried out on 5th May 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 30/09/06

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 Mrs Zeta Joseph Unannounced Inspection 5th May 2006 09:00 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.V291087.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 DS0000017019.V291087.R01.S.doc Version 5.1 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 Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 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. 8th September 2005 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. 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 pleasant garden to the rear of the property; a patio area was being completed at the time of the inspection. Egress from the home into the rear garden is conducive for wheelchair users and people with mobility difficulties. 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. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and took three and a half hours. The Manager on duty confirmed, there were twenty four residents currently living at the home. In addition to the Manager, there were three care staff on duty plus three further ancillary staff. The Manager and owners were interviewed and six residents were spoken to. The building was toured and residents’ care plan records, medication MAR charts, health care, risk and manual handling assessments and daily records were examined. The Inspector is concerned that when requirements from previous inspections are met these are not implemented within the home continuously. The Inspector noticed that over a period of time the home reverts to poor practice as found at previous inspections, the Registered Manager must take full responsibility for this. West Midlands Fire Service has undertaken a fire inspection and there are outstanding requirements relating to their findings. What the service does well: What has improved since the last inspection? The Responsible Individual has provided the Manager with supervision measured against outstanding requirements and monitoring checks undertaken Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 6 so that the manager’s competence in leadership and supervision are measured against practice within the home. There were no outstanding concerns relating to complaints received by the Commission. What they could do better: Compliance with the fire inspection and outstanding matters must be urgently dealt with. A statutory requirement and serious concerns letter was brought to the attention of the Manager and Responsible Individuals at the inspection undertaken in July and August 2004. The manager must improve her performance so that the home meets the minimum standards. A statutory requirement and serious concerns letter was brought to the attention of the Manager and Responsible Individuals at the inspection undertaken in July and August 2004, April and September 2005. The home has a stale odour of urine and some toilets were dirty with dried faeces; snail trails were seen in a ground floor bedroom, as a consequence of this, management of infection control must improve. A statutory requirement regarding this matter was brought to the attention of the Manager and Responsible Individuals at the inspection undertaken in April 2005. Residents had their own personal copy of the Service User Guide; however the Manager confirmed that these were also residents’ contracts, when examined these documents were found not to be individualised. A statutory requirement regarding residents’ contracts was highlighted during an inspection in 2004 a subsequent inspection and examination of records revealed that contracts were in place for residents, this has not continued as practice. Care plan records for new residents were not up to date because the Manager has introduced new methodology based on a quality assurance system to a workable pre-existing system. The Manager when asked was not able to describe the benefits of changing recording systems. A daily report indicated that a resident had urine problems but there were no recordings in the care plan to substantiate the Managers explanation of when the resident returned to hospital for medical intervention. There were no recordings of fridge and freezer temperatures since February 2006 because the home had run out of recording sheets. Examination of the some of the documentation of the quality assurance system revealed that recording sheets were available for use. Two radiators were found to be very hot, the surface temperatures of radiators situated in the dinning area and ground floor hallway must be reduced and Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 7 radiator covers fitted so that residents and visitors who have access to these are not put at greater risk. The Manager must continue to liaise with Health Care Practitioners so that residents benefit from improve health care especially residents discharged from hospital. The current prescription must be filed with residents MAR chart records. The drugs trolley must be secures to a solid wall. 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 DS0000017019.V291087.R01.S.doc Version 5.1 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 Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 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): 2,3,4,5 Residents’ contracts or terms of condition must comply with the minimum standards and a signed document provided for each resident; a copy must be contained within their personal care file. No pre-admission documentation for a new resident. EVIDENCE: Residents’ were provided with a Service User Guide, the Manager confirmed this was the residents contract; these were not individualised and do not meet the standards. This was highlighted at a previous inspection and the Manager implemented this with new residents at that time but there has not been any continuity to this to date. A needs assessment from Social Care and Health was in place for new residents. Documentation relating to pre-admission were incomplete and were not robust enough to indicate how the home will meet needs. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Management of residents health care plan is not robust enough and all residents are provided with a plastic mattress cover regardless of whether the resident needed this. Management of medicines is good. The medicine trolley must be rag bolted to a solid wall; this is an outstanding requirement. Residents sharing a room must be given an informed choice of a suitable single room with records maintained. Staff are provided with training in death and dying as confirmed by the Managers action plan to the Commission. EVIDENCE: During the tour of the building the Inspector saw that most beds were fitted with a plastic mattress cover; when asked the reasons for this the Manager confirmed where identified residents were assessed as requiring these and as a Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 11 precaution fitted plastic mattress covers to the remainder of beds, clearly disregarding the needs of the resident who do not need this. The Manager must ensure that professional advise about the promotion of incontinence is sought. The content of new care plans are poor and do not detail actions to be taken by staff to ensure all aspects of care delivery continue to be met. Residents’ medical records and charts are satisfactory; the most up to date prescription must be kept on file and the remainder filed within the residents personal care file. The medication trolley must be rag bolted and secured to a solid wall; this is an outstanding requirement. When asked about resident’s choice to move out of a shared room to a suitable single room the Manager did not demonstrate how she promoted this. The Inspector noticed that a resident with a dementia illness was sharing with another resident without dementia; concerns were raised regarding their compatibility. The Manager confirmed that training in death and dying is ongoing on the training programme since November 2004. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The Manager must ensure that residents are offered appealing choices of meals. EVIDENCE: The menu was examined; the choices available were not varied and appealing. There are no alternatives on Thursdays and records are kept of residents choice of meal; a high number of residents choosing egg and potato mash as an alternative. The cook is on duty Monday to Friday and there is not indication of who covers the weekends. Concerns regarding meals were raised as a requirement in July 2004 it is clear that the Manager has not ensured that this standard continue to be met. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20, 21,23, 24,26 The cupboard door to a wash hand basin in Room 6 has broken hinges, some headboards were stained, wall plaster in one bedroom was badly cracked and peeling. Carpeting to the stairs is worn and need to be replaced. The Manager must demonstrate how she ensures that residents access communal facilities in and outside the home. The Manager must demonstrate how positive choices for residents who share bedrooms are encouraged. Television facilities must be provided for residents seated in the 2nd lounge. Radiators to the hallway and dinning areas must be covered so that the safety of people who have access to them are fully protected. The provision of toilet and bathroom facilities on the ground floor must be reviewed so that residents’ needs are met. Snail trails in Room 5, constant smell of stale urine on the first floor and from one of the bedrooms. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 15 EVIDENCE: The cupboard to the shared wash hand basin in room six is broken and must be repaired or replaced. The plaster to one of the upstairs bedrooms is badly cracked and the resident’s bed is positioned next to this, the stair carpet is worn and constitutes a hazard to people using it. The toilets and ground floor bathroom are inadequate in accessibility and dimension to enable staff to safely manually handle residents’ with mobility difficulties and those who use a wheelchair. The owner confirmed at the September 2005 inspection that residents with mobility difficulties were being toileted in the larger upstairs bathroom. The owners have submitted draft plans to the Commission in regard to an extension to the ground floor; this will include adapted showers, bathing and toileting facilities, a refurbished kitchen and new conservatory. The owners must demonstrate how residents will benefit from these adaptations. There are no start dates for this extensive work. The requirement for upgrading the toilet and bathing facilities remain outstanding from 2004 remains outstanding from 2004 inspections. There are some shared bedrooms occupied by two residents; the Manager will need to demonstrate how residents make a positive choice to share and continue to share with each other especially as there are empty bedrooms available. In one of the communal lounges the television was not working because of the inadequate aerial. The television screen is no more than 15 inches and is far too small for residents to see the programmes. At the last inspection there were noticeable improvements in the management of cleanliness that ensured that residents live in a safe and hygienic environment; this has since deteriorated because the Manager had not continued with robust auditing of cleanliness throughout evident by strong smell of urine on the first floor landing. A requirement was made of robust infection control management in July 2004 in order that the Manager implements an infection control audit based on the one conducted by the Infection Control Nurse in January 2004. During the tour of the building the Inspector noticed that liquid soap containers were refills and not the pump variety that enabled residents to use these easily. Hardened faeces were noticeable on various toilets and radiators in the dinning area and hallway were very hot to touch and must be covered so that the surface temperature is lowered. At the July 2004 inspection a requirement was made for a risk assessment to be in place where radiators were not Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 16 guarded within communal areas. The Managers response to this did not relate to a robust health and safety risk assessment. The Manager confirmed that all beds were covered with plastic sheeting; when asked the reason for this the explanation given was not plausible and conflicted with the District Nurses’ explanation to the Manager that residents will perspire and sustain skin lesions from plastic sheeting. The Manager is not complying with the required standards for safe continence management and did not contact the District Nurse for advice. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 17 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, There are insufficient domestic staff employed to ensure robust cleanliness and hygiene. The training of staff had been undertaken with dates in May 2006 for further training; training certificates will be available at a later date. EVIDENCE: The Manager confirmed there were gaps in cleaning and laundry. There were three care staff and the Manager on duty to meet the needs of residents during the day. The Manager confirmed that mandatory training had been provided for staff. NVQ level 3, Health and Safety, Customer Care, Fire Training, and Manual Handling. The Manager will need to confirm whether induction and the above courses meet the Skills for Care foundation standards and the training matrix must be reproduced; a requirement for these was made at the December 2004 inspection. As there were no new staff recruited the standard for robust recruiting was not assessed. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31, 32, 33, 36, 37, 38 The Manager will need to complete an NVQ level 4 qualification in Management. The Manager has not demonstrated how she manages the home competently. The Manager is being closely supervised but supervision of care staff by the Manager has not taken place despite this being recorded as part of the Managers action plan to the Commission. Resident’s and care staff records are abysmal and are not maintained by the Manager. Resident’s health and welfare are not protected by safe working practices. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 19 EVIDENCE: The Inspector had negotiated with the Manager an extension to the date of completion of the NVQ qualification to 31st May 2006. Similar excuses were made as to why the qualification has not been achieved. The Manager receives support and performance supervision from the Responsible Person. The Managers supervisory records were available for examination and the Inspector discussed progress in the Managers performance and work practice with the Responsible Person. When asked, the Manger offered no plausible explanation as to why evening care staff had not been provided with supervision. The Inspector was unable to decipher residents and staff records from the hap hazard storage undertaken by the Manager; requirements were made of this and a part time administrator employed who has worked hard to develop a robust system; but the Manager works in such an unsystematic way that is evident by her record keeping, inability to forward plan and her excuses for not leading in care practice so that the aims of the home is promoted. The Responsible Person has purchased a quality assurance system to monitor the current policies and procedures implemented so that outcomes are measured and acted on. Instead of following instructions from the Responsible Person the Manager ignored instructions and has introduced new recording systems from the quality manual such as care planning. As a consequence of this she has not completed care plan assessments, contracts/terms of conditions, and not implemented formats available for example to record temperatures of the freezer and fridge which have not been recorded since February 2006. The Managers familiarity with the new quality system is at best poor and she was unable to locate forms to implement so that that progress is made in the recording system. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 1 3 2 1 N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 1 2 2 1 2 2 1 STAFFING Standard No Score 27 2 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 1 X X 1 1 2 Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 21 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 has improves service delivery. THIS REQUIREMENT REMAINS OUTSTANDING from 01/12/04 The Registered Person is required to ensure there are sufficient trained and competent staff working in the care home that are trained in dementia and care planning to meet residents’ needs. THIS REQUIREMENT REMAINS OUTSTANDING from 30/08/04 There must be clear documentation maintained of pre-admission/trial visits before the decision is made to stay permanently. Advice and guidance from health care practitioners must be recorded in care plans, reflected in work practice and demonstrated within continuity of service delivery. DS0000017019.V291087.R01.S.doc Timescale for action 16/06/06 2. OP4 17(1) 16/06/06 3. OP5 17(1) 01/08/06 4. OP7 13(1)(b) 16/06/06 Rosemary Lodge Version 5.1 Page 22 5. OP8 13(1)(b) 6. OP9 23(1)(a) THIS REQUIREMENT REMAINS OUTSTANDING from 30/08/04 Residents must be enabled to access community health care professionals to benefit from screening when discharged from hospital. Residents records must evidence this THIS REQUIREMENT REMAINS OUTSTANDING from 08/04/05 The Medication trolley/cabinet must be rag bolted and secured to a solid wall. A more robust infection control audit must be implemented to reduce the smell on the 1st floor. Liquid soap must be dispensing containers so that residents can use them. REQUIRMENTS RELATING TO INFECTION CONTROL ARE OUTSTANDING from 04/08/04 The Registered Manager shall demonstrate how residents’ are empowered to exercise their choices and preferences within the home. E.g. shared rooms THIS REQUIREMENT REMAINS OUTSTANDING from 25/04/05 Residents must be offered appropriate varied, appealing and nutritious meals so that residents with assessed specific dietary needs are met. Suitable alternatives must be available as advised by the health care/dietetic care professionals. THIS REQUIREMENT REMAINS OUTSTANDING from 31/08/04 The qualifications and training of the cook and kitchen assistant must be evidenced. The Registered Person must ensure that the care home is kept in a good state of repair as per the schedule provided to the DS0000017019.V291087.R01.S.doc 16/06/06 30/05/06 7. OP10 12(4) 16/06/06 8. OP14 12(2) 16/06/06 9. OP15 13(1)(b) 16(2)(i) 16/06/06 10 11. OP15 OP19 16(2)(i) 23(2)(b) 31/05/06 16/06/06 Rosemary Lodge Version 5.1 Page 23 12. OP19 23(2)(b) 13. OP20 23(2)© 14. OP21 23(2)(n) 15. OP22 23(2)(n) Commission. THIS REQUIREMENT REMAINS OUTSTANDING from 31/08/05 The care home must be in a good state of repair; Room 25 bedroom wall must be repaired so that the resident is not sleeping next to cracked walls. Room 6 cupboard door to the wash hand basin is broken and the headboard is stained. Carpeting to the stair treads are worn and constitute a hazard to the user. Facilities in the lounge must contain equipment that is in working order e.g. broken television aerial and the screen is far too small for resident’s enjoyment. 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 OUTSTANDING from 01/12/04 The Registered Person must provide evidence that the recommended adaptations to the home will meet residents’ needs. THIS REQUIREMENT REMAINS OUTSTANDING from 30/09/04 Residents must be provided with informed choice to share and given the opportunity to move to a different room when one becomes available; records must be maintained of this. The Registered Person shall ensure each resident is not provided with a plastic mattress DS0000017019.V291087.R01.S.doc 30/05/06 30/05/06 16/06/06 16/06/06 16. OP23 23(2)(e) 30/05/06 17. OP24 14(2) 30/05/06 Rosemary Lodge Version 5.1 Page 24 covering unless assessed as needed these; records must be maintained and detailed in the care plan. 18 OP25 13(4)(a) The radiators in the dinning area and hallway have very hot surface temperatures. These must be guarded or have guaranteed low temperature surfaces. The Action plan re Inspection requirements for July 2004 provided by the manager indicates that ‘radiators in communal area will be covered budget but have been risk assessed’ A copy of the risk assessment must be forwarded to the Commission. The premises must be clean, hygienic and free from offensive odours. An audit of the home must be conducted using the format supplied by the Health Protection Nurse. Domestic staff must be employed in sufficient numbers to ensure that standards relating to food, meals and nutrition are fully met, and the home is maintained in a clean and hygienic state, free from dirt and unpleasant odours. The Registered Person shall ensure staff induction and mandatory training complies with Skills for Care (previously TOPSS) foundation standards. THIS REQUIREMENT REMAINS OUTSTANDING from 01/12/04 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. DS0000017019.V291087.R01.S.doc 30/05/06 19. OP26 16(2)(k) 30/05/06 20. OP27 18 30/06/06 21. OP28 18(1) 16/06/06 22. OP30 19(1), 10(3) 16/06/06 Rosemary Lodge Version 5.1 Page 25 23. OP31 10(1) 24. OP31 18(1) THIS REQUIREMENT REMAINS OUTSTANDING from 01/07/05. 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, an action plan submitted to the Commission. THIS REQUIREMENT REMAINS OUTSTANDING from 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. 16/06/06 30/05/06 25. OP32 18 26. OP33 35 27. OP36 18©(i) The Registered Person shall 16/06/06 ensure the Manager manages the home in an open and transparent manner and communicates clear direction and leadership for staff and residents. Eg the introduction of Managing Absence/Return to Work Interviews. The Responsible Individual must demonstrate to the Commission the support provided to the Manager to enable her to carry out her duties. THIS REQUIREMENT REMAINS OUTSTANDING from 30/11/05. An effective quality assurance 16/06/06 and quality monitoring system must be implemented that meets the standards. Systems and structures must be in place to monitor the quality of services being provided. THIS REQUIREMENT REMAINS OUTSTANDING from 01/12/04 Formal supervision of all staff 16/06/06 DS0000017019.V291087.R01.S.doc Version 5.1 Page 26 Rosemary Lodge 28 OP37 17(1) 29. OP38 18(1) must take place six times per year with records maintained in individual staff files. THIS REQUIREMENT REMAINS OUTSTANDING from 30/08/04 Records required for the protection of residents and for the effective and efficient running of the business must be maintained, up to date and accurate. THIS REQUIREMENT REMAINS OUTSTANDING from 01/12/06. The Registered Person must ensure that supervision processes includes employment policies and procedures adopted by the home and its induction and training arrangements are put into practice within care staff supervision. THIS REQUIREMNET REMAINS OUTSTANDING from 30/11/05 Requirements from the fire inspection undertaken by the Fire Service 03/05/06 must be 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 not for example perch the ladder on a brick. REQUIREMENTS RELATING TO THIS REMAINS OUTSTANDING from 28/07/04 Fridge and freezer temperatures must be maintained. 16/06/06 16/06/06 30. OP38 23(4) 03/08/06 31. OP38 16(1) 16/06/06 31. OP38 16(2)(g) 20/05/06 Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 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. Refer to Standard OP37 Good Practice Recommendations That the layout of the signing in/out record book is improved. Rosemary Lodge DS0000017019.V291087.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 DS0000017019.V291087.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!