Inspection on 08/04/05 for Rosemary Lodge

This inspection was carried out on 8th April 2005.

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 05/05/06

Rosemary Lodge 08/09/05

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 B14 6AA Lead Inspector Zeta Joseph Unannounced 8 April 2005 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 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 E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Rosemary Lodge Address 154 Alcester Road South Kings Heath Birmingham B14 6AA 0121 433 1166 0121 442 6454 Telephone number Fax number Email 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 Older People registration, with number of places Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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. Date of last inspection 21 December 2004 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 E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector conducted a joint inspection with the District Nurse who assisted with the inspection particularly in regard to residents’ health care and safety. On the day of inspection there were 21 residents living at the home. The Inspector met with residents, interviewed care staff and the manager. The building was toured and residents care plan records were examined, these included health care assessments that are written to explain how the home will meet the needs of residents’. The Inspector returned to the home on 13th April 2005 to examine residents records relating to falls, admittance to hospital, discharge to Rosemary Lodge and the management of residents health care. What the service does well: What has improved since the last inspection? The content of written recording within service users care plans and daily records has improved. The Provider has adhered to the recommendations of the fire inspection conducted by the Fire Officer that took place in August 2004. The Manager and Senior Care staff have been provided with training to manage Control of Substances Hazardous to Health (COSHH) items. Although some service users records indicated that they had benefited from nutritional assessments; it was clear from records examined by the Inspector that some service users had not been referred to a health care professional when their health deteriorated. The Registered Manager has implemented good medicine management and ensures that prescriptions are checked and recorded against Mar charts and prescriptions are photocopied. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 6 The Complaints Policy includes the details of the Commission so that service users can exercise their right to complain independently. During the tour of the home the Inspector saw that headboards had been fitted to some beds as identified by the Inspector at the last inspection, there were some outstanding. Within the kitchen food items were seen to be stored as per food safety guidelines. What they could do better: A complaint was outstanding at the time of the inspection; this is being followed up by the Responsible Individual in line with the complaints procedure for the home. An Infection Control Audit took place in 2004; the Manager will need to implement recommendations from this so that infection control is robustly managed and that tasks relating to this are effective when cascaded to staff. The Commission had received a report from a health centre relating to poor health care of service users referred to them; the Responsible Individual must ensure the Manager improves liaison with Health Care Professionals, specifically District Nurses so that service users referred to the local medical centre attend with correct details. District Nurses must take the lead in invasive medication management. The Registered Manager had not informed the Commission about incidences of scabies and deaths at the home. The District Nurse was not contacted for her professional guidance and involvement in the continuing health care of residents. The Registered Provider must ensure that the Manager is provided leadership management for the Registered Manager with records retained for inspection, so that the Manager improves her competences in completing work practice tasks, delivers residential care to service users safely and manages all staff in meeting minimum standards. The Registered Provider must support the Manager to follow up concerns raised with senior care staff about their work practice. The Responsible Individual must ensure the dinning room chairs are replace because these are threadbare and constitute a health hazard for residents. The dinning area could be re-arranged so that residents requiring a wheelchair can be moved about safely. There is a 2nd lounge for service users to sit in where activities should take place during the day. The Manager must ensure the Commission is informed of Regulation 37 concerns in a timely manner. The continuation sheets relating to service users care plan and daily records must be implemented to provide better clarity for inspection. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 7 The Commission are waiting for a response to their letter of serious concern of issues found at inspection. 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 E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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 standard(s) Not inspected EVIDENCE: Not inspected Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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 standard(s) 7,8,9 Residents’ health care needs are not fully met and reassessments on return from hospital are not consistent. Procedures for dealing with medicines are not fully adhered to including one incident of inappropriate administration of invasive medication. EVIDENCE: It was clear that the Manager had administered medication to a resident this action was beyond her managerial responsibilities and job description. The Manager wrote to the Commission admitting to this and taking full responsibility for her action. The Manager had recorded on a resident’s file that she had given a resident three suppositories on two different occasions. When told by the Inspector that she was administering invasive medication and acting beyond the scope of her post as a Manager with no nursing skills, experience or qualifications, she said that she thought she could administer these. A resident was sitting in the small lounge area with three different containers of creams. When asked about this, the Manager did not have an explanation; Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 11 she confirmed that the service user is not self-medicating. The resident’s records indicated that she was not self medicating. The resident’s service user records examined by the Inspector contained assessments of their needs; the home completes a care assessment for each resident to confirm that the home can meet their needs. From the incidences that occurred within the home, meeting resident’s needs is not borne out in practice. From the records examined by the Inspector, some residents were found to have had scabies, some residents had sustained falls and had been admitted to hospital and some residents had pressure sores; neither the Commission nor the District Nurses had been informed of these incidences. Where residents had returned to the home from hospital, the Manager was not consistent in conducting a re-assessment of their needs involving health care professionals. The Inspector saw a resident with three packets of creams in her possession. When asked about this the Manager offered no explanation. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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 standard(s) Not inspected EVIDENCE: Not inspected Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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 standard(s) 16 Documentation relating to an outstanding complaint concerning a number of pertinent issues; the Registered Manager had not been investigated within the timescales of the homes complaints policies and procedures. EVIDENCE: The complaints policy has recently been amended to include the correct details for the Commission. Although these are in place the Inspector was not confident that complaints were being acted upon. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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 standard(s) 19,21,22,24,25,26 Residents’ safety and comfort is compromised by use of threadbare and dirty chairs in bedrooms, dinning areas and lack of headboards. Toilets are too small to allow safe access for wheelchair users with care staff. Changes must take place to ensure appropriate infection control practice to ensure residents’ live in a safe and hygienic home. EVIDENCE: There was a stagnant smell of urine throughout the home. During the tour of the home the Inspector noticed that a resident occupying Room 10 had plastic sheeting covering her mattress. When asked about this it was established from the Manager that she had not purchased continence sheets and washable mattresses for residents who clearly needed them. Concerns were raised by the District Nurse to the Manager in regard to residents’ perspiring and sustaining skin lesions from the plastic sheeting. The Manager did not offer a satisfactory explanation and was not complying with the required standards for safe continence management. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 15 The chairs in the dinning area were threadbare and could cause unnecessary pressure to residents’ sitting in the chairs for prolonged periods of time. A number of chairs in the dining room and in residents’ bedrooms had plastic bin liners covering the chair seats; the bedroom chairs were those that were in the dinning area previously and were deemed too threadbare to remain in the dinning area, the Inspector suggested that the bedroom chairs are removed and replaced by suitable and appropriate furniture. A number of resident’s beds did not have a headboard fitted; these concerns were raised with the Responsible Provider and the Manager; an explanation for this was not forthcoming despite a requirement for this to be done at the last inspection and an Action Plan provided to the Commission. The home was subject to an audit in January 2004 by the Infection Control Nurse, a report that clearly describes the methods the Manager must implement in the home to maintain high standards of infection control is available in the home. The Manager was asked to implement these changes so that infection control can be safely managed. The Registered Provider and the Manager has been left with requirements at previous inspections in regard to this. A resident was being treated for MRSA; the District Nurse is aware of this and provides professional advice and monitoring in regard to safely managing this. Residents’ personal items of nailbrushes, soap and flannels were in various communal bathrooms. There were no paper towels or liquid soap in various bathrooms and toilets throughout the home; where paper towels, toilet rolls or liquid soap were seen these were out of reach for the resident using the facilities. A care assistant was observed having toileted a resident and then went on to perform personal care of another resident; the care staff was not wearing disposable apron and gloves. Where care staff were observed wearing disposable gloves and aprons these were not disposed of when caring for one resident to another. In one of the ground floor toilets clinical waste had been put into a dustbin that was not the designated clinical waste bin; when asked about this the Manager was not able to demonstrate her understanding of the clinical waste procedure for the home, her explanation conflicted with the procedures for the home. During the tour of the building a pipe in the ensuite to room 12 was leaking. The toilets throughout the home are inadequate in size to safely manual handle wheelchair users. In a shared bedroom number 8 three wheelchairs were being stored; concerns were raised in regard to cross infection and the Inspector suggested that an alternative room be found for storage. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Residents’ needs were not fully met as staffing numbers fell below standards. Residents’ were not fully supported and protected due to incomplete recruitment processes (CRB) and care staff not being fully trained resulting in poor manual handling and infection control practices. EVIDENCE: At the time of inspection the staffing numbers fell below standards; there were two staff on duty for twenty-two residents. Three staff had not turned up for work. The Manager confirmed to the Inspector that three staff (two care staff and one cook) had not turned up for work and despite having previous knowledge of this she had not managed to increase staffing levels. The Manager started to arrange for additional cover after this was brought to her attention. She contacted the Registered Provider for additional staff to be brought over from another home owned by the Registered Provider; this was done without compromising the staffing levels at the other home. The Inspector examined staff files and saw that the home had not implemented robust recruiting methods to protect service users from potential harm by applying for an Enhanced Criminal Records Bureau (CRB) for all staff employed at the home. The Manager and care staff were observed applying poor manual handling methods when handling a resident. A care assistant was pushing a resident in a wheelchair, there was no footrests or safety belt fitted; the care assistant Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 17 then attempted to toilet the same resident in a toilet area that was inadequate in size to perform this task safely. The Inspector asked the Manager to demonstrate using a hoist stored in a residents’ bedroom. The Manager was not able to demonstrate this because the hoist could not fit under the residents’ bed. When asked about hoist and wheelchair training, the Manager confirmed that training had been provided for the staff; the Inspector required that staff (including the Manager) be provided with appropriate training to ensure they can safely use wheelchairs and hoisting equipment to safely handle residents. Written concerns recorded by the Manager regarding staff poor work practice had not been followed up to a satisfactory conclusion. Care staff would benefit from Infection Control training because they were seen by the Inspector toileting and attending to personal care of another resident without wearing disposable aprons and gloves. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,38, The health, safety and welfare of service users is not fully promoted due to poor management of risks and hazards and failure to notify the Commission of incidents as required by regulation. EVIDENCE: The Inspector identified records where a number of residents had sustained falls at the home, had been admitted to hospital, and/or had died at the home or in hospital. There were unreported incidences of scabies at the home. The Responsible Individual must provide evidence to the Commission about how the Manager has been supervised since 2003 to ensure the home is managed in the best interests of service users. The Manager did not have access to her supervision notes and was not able to explain how she was supported by the Registered Provider in relation to her own management practice. The Registered Provider must support the Manager to follow up concerns raised with senior care staff about their work practice. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 19 The Manager must adhere to safety standards and ensure that the lift motor room door is kept locked at all times. The Manager did not offer a satisfactory explanation as to why the lift door was unlocked. An unused shower room was unlocked during the inspection; the shower tray in the room constituted a trip hazard for residents who may wander into this room. The Inspector requested that the unused shower room is locked until it is suitable for use. A smoke detector/alarm was not fitted in Room 24; the Manager confirmed to the Inspector that the resident occupying the room smoked. When the resident’s record was examined there were no recordings within the risk assessment relating to safeguarding the resident from accidents relating to smoking. The Inspector and the District Nurse observed care staff not adhering to safe Health and Safety Policies and Procedures, such as: A member of staff was observed pushing a resident in a wheelchair without previously fitting the footrests and lap belt. The manual handling technique used by the staff to transfer the resident from the wheelchair to the toilet was, in the Inspectors opinion a very dangerous practice. Furthermore the toilet is far too small to accommodate a safe transfer; the Inspector brought this to the attention of the staff involved, the Manager and Registered Provider. Prior to this inspection, the District Nurse saw a member of staff physically lift a resident from her chair. The hoist was stored in another resident’s bedroom because of lack of storage facilities within the home. When shown the hoist handling techniques by the Manager it was evident that the hoist could not fit under the bed of the resident requiring hoisting. The Manager did not provide an explanation as to how the resident was safely hoisted. Staff were not wearing a disposable apron when toileting a service user; the same staff was seen performing personal care, again not wearing the correct attire. The Manager had not notified the Commission by Regulation 37 relating to 40 incidences of falls, pressure sores, and admittance to hospital, scabies, and death at the home and at hospital. The Inspector examined residents’ records from August 2004 and identified where these incidences occurred. Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 1 x 1 1 1 2 1 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 Standard No 16 17 18 Score 1 x x 1 1 1 x x x x 1 Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4©,5© Requirement The Registered Person shall ensure the Statement of Purpose and Servic e User Guide includes how refurbishments has improved service delivery.Previous timescale of 1st December 2004 not met. The Registered Person is required to ensure there are sufficiently trained and competent staff working in the care home who are trained in dementia and care planning training to meet service users needs. Previous timescale of 30th August 2004 not met. The Registered Manager must demonstrate effective liasion with Health Care Proffessional to ensure that the needs of service users are continuously met. The Registered Person shall ensure where advice/guidance is provided by a Health Care Professional that this is reflected within all service users individual care plans and demonstrated within service delivery and work practice. THIS REQUIREMENT REMAINS OUTSTANDING. Timescale for action 1st Dec 2004 2. OP4 17(1) 30th August 2004 3. OP7 13(1)(b) 8th April 2005 and ongoing 30th August 2004 4. OP7 13(1)(b) Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 22 5. OP8 6. OP8 7. OP8 8. OP9 9. OP9 10. OP9 11. OP14 The Registered Person must ensure service users health care is maximised at the home and demonstrate how service users are enabled to receive medical advice from Health Care Professional(s). 13(1)(b) The Registered Manager must demonstrate that service users are thouroughly re-assessed with records revided where the service user is returned to the home from a stay in hospital. 13(1)(b) The Registered Person shall ensure that service users are enabled to access Community Health Care Professionals that service users can benefit from nutritional assessments and screening. THIS REQUIREMENT REMAINS OUTSTANDING. 18(1)(a) The Registered Manager must not administer medication unless she is appropriately trained to do so. The Manager must work within the scope of her duties, job descripion and medication policies of the home and manage medication more robustly within the home so that service users are not at risk of harm. 18(1)(a)(c The Registered Person shall ) ensure that the Registered Manager completes an accredited medication training course; a certificate of completion must be available for inspection. 13(2) The Registered Manager shall ensure that service user MAR charts and copies of prescriptions are filed within individual service user files. THIS REQUIREMENT REMAINS OUTSTANDING. 12(2) The Registered Manager shall demonstrate how servic eusers are empowered to exercise their E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc 13(1(b) 8th April 2005 and ongoing 8th April 2005 and ongoing 30th August 2004 8th April 2005 and ongoing 3oth November 2005 31st Dec 2004 25th April 2005 Page 23 Rosemary Lodge Version 1.30 12. OP16 22(1) 13. OP19 23(2)(b) 14. OP19 23(2)(L) 15. OP21 23(2(n) 16. OP21 23(2)(n) 17. OP22 23(2)(a) choices and preferences within the home. The Manager must manage complaints received into the home from service users representatives and follow the home complaints policy. The Registered Person must ensure that the care home is kept in a good state of repair as per the schedule provided to the Commission. THIS REQUIREMENT REMAINS OUTSTANDING. The Responsible Person shall ensure there is adequate and suitable provision made for storage of equipment for the purposes of the care home so that service users private bedrooms and shared communal space is not used for storage. 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 service users. The plans, when submitted to the Commission, must have time scales indicating when work is to be carried out. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person shall ensure where service users requiring a wheelchair to mobilise that these are maintained and the rooms used for transfer are adequate to safely transfer and handle the service user(s). The Registered Person must review the layout of the home with regard to improving signage (fire exits), decoration, lighting and labels on bedroom doors for service users suffering from dementia. THIS REQUIREMENT 19th April 2005 31st August 2004 30th September 2005 1st December 2004 30th April 2005 30TH September 2004 Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 24 REMAINS OUTSTANDING. 18. OP22 23(2)(n) The Registered Person must consult with a suitably qualified person(s) with specialist knowledge of the client group and carry out professional assessments of service users.THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person must provide evidence that the recommended equipment/furniture/adaptations meets the needs of service users. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person shall ensure records are maintained on individual service users files. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person shall ensure suitable equipment such as wheelchairs are used and/or purchased with the correct attachments such as footrests and safety belt and that hoists are suitable for the purpose for safely transfering service users. The Registered Person must ensure that the practice of putting discarded dinning room chairs in service users bedrooms and covering these with bin liner must cease immediately.The Inspector saw these in rooms 11, 15, 16, 19, 20, 21,22,24. Adequate private and communal seating must be provided for service users and visitors. THE REQUIREMENT TO REPLACE DINNING ROOM CHAIRS WAS MADE IN AUGUST 2004; THIS REMAINS OUTSTANDING. The Registered Person must provide furniture for each service user as stated in this standard; 30th September 2004 19. OP22 23(2)(n) 30TH September 2004 20. OP22 17(3)(b) 30th September 2004 8th April 2005 21. OP22 23(2)(n) 22. OP24 23(2)(e) 30th July 2005 23. OP24 23(2(g) 1ST December 2004 Page 25 Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 24. OP24 23(2) 25. OP25 23(2)(p) 26. OP26 16(2)(k 27. OP26 13(3) 28. OP26 13(3) this must include headboards (Room 20), unless at the expressed wish of the service user they do not want such furniture, this must be supported by an appropriate risk assessment. Records must be kept for inspection purposes. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person shall ensure that a suitable smoke detector is fitted where service users smoke eg Room 24; and that the equipment is maintained. The Registered Person shall ensure suitable lighting is provided in all parts of the home eg outside the bathroom on the first floor. The Registered Manager must adhere to the recommendations within the Infection Control Audit that was carried out at the home by the Infection Control Nurse in January 2004 and ensure the premises are kept clean and free from offensive odours; there was a stagnant smell of urine throughout the home. A REQUIREMENT RELATING TO CLEANLINESS OF THE HOME IS OUTSTANDING SINCE JULY 2004. The Registered Person shall ensure all staff including the Manager at the home wear disposable gloves and aprons when carrying out personal care tasks involving service users. Disposable items must be discarded as clinical waste when staff move from service user to service user. The Registered Person must ensure clinical waste is robustly managed throughout the home 11th April 2005 11th April 2005 8th April 2005 and ongoing 8th April 2005 and ongoing 1st June 2005[ Page 26 Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 29. OP26 13(3) 30. OP26 13(3) 31. OP26 13(3) 32. OP27 18(1)(a) 33. OP27 18(1) 34. OP28 18(1) and provide staff including the Manager with training to ensure understanding of their responsibilities and of the homespolicy relating to managing clinical waste within the home and that it becomes a continous practice at the home. To reduce cross contamination and the spread of infectious disases,the Manager must ensure nail brushes, flannels and soap are removed from communal bathrooms without delay. THIS REQUIREMENT REMAINS OUTSTANDING. The Manager shall conduct an Infection Control Audit within the home using the format already supplied. These records must be available for inspection. The Manager shall ensure sufficient paper towels and liquid soap are available in toilets and bathrooms and are accessible for service users. The Manager must ensure there are suitable, competent and experienced staff on duty in sufficient numbers who can care for service users health and welfare needs. On the day of inspection at a peak time there were 2 staff on duty to care for 22 older residents. A copy of the planned duty rota must be available The Registered Person shall, having regard to the size of the care home, the statement of purpose, low staffing ratios, the number and needs of service users, consider reducing numbers of bedrooms available at the home. The Registered Person shall produce a comprehensive training matrix that clearly 8th April 2005 13th April 2005 8th April 2005 8th April 2005 1st September 2005 1st December 2004 Page 27 Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 35. OP29 19, Sch 2 36. OP30 18(1) 37. OP30 18(1) 10(3) 38. OP31 10(1) 39. OP31 18(1) 40. OP31 18(1) relates to NVQ and TOPSS related courses provided for care staff. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person must ensure that staff files comply with Schedule 2 of the above regulations and a robust recruitment process is implemented to protect service users. All staff must undertake an Enhanced CRB check under the provisions of POVA. These records must be available for inspection. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person must ensure that staff induction training is compatible with TOPSS specifications. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person shall ensure all staff including the Manager are provided with accredited training in safe manual handling techniques, including wheelchair training. The Registered Person and Manager shall, having regard to the health and safety of service users, manage the home with sufficient skill and competence. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person shall ensure the home is managed by a qualified and competent person and provide training for the Manager appropriate to the work she is employed to to do. Records of suitable traning provided must be available for inspection. The Manager must provide evidence to the Commission of qualification to NVQ level 4 in Management or equivalent. 1st December 2004 1st December 2004 1st July 2005 27th July 2004 1st September 2005 and ongoing 1st September 2005 Page 28 Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 41. OP32 18 42. OP36 18(2) 43. OP38 13(4)(a) 44. OP38 23(2)(a)( b) 45. OP38 23(2) 46. OP38 16(2)(ii) 47. OP38 17(1)(a) Sch 3 The Registered Person shall ensure the Manager manages the home in an open and transparent manner and communicates clear direction and leadership for staff and service users. The Responsible Individual must demonstrate to the Commission the support provided to the Manager to enable her to carry out her duties. The Responsible Person must ensure all staff at the home including the Manager is provided with appropriate supervision. Where staff are subject to the disciplinary process, records relating to how they were performance managed prior to and after the actions must relate clearly to the disciplinary actions taken. These records must be available for inspection. The Manager shall ensure safe pratice within the home and keep the lift motor room locked at all times. The Manager shall ensure the unused shower room is kept locked; the shower tray constitutes a trip hazard for service users who have acces to this. The Responsible Person shall ensure a smoke alarm is fitted in Room 24 and that it is maintained. The Manager shall ensure the fax machine is working and report broken office equipment to the Registered Person. The Manager shall maintain records of any incidence(s) affecting the service user in the care home and of any other incident which is detrimental to 13th September 2005 1st July 2005 8th April 2005 8th April 2005 13th April 2005 and ongoing 8th April 2005 and ongoing 13th April 2005 and ongoing Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 29 48. OP38 37 49. OP38 18(1) 50. OP36 18©(1) the health or welfare of the service user. The Registered Person shall notify the Commission without delay any incidence(s) affecting the service user or staff within the home. The Registered Person must ensure that all staff receive mandatory training plus updates each year. Eg manual handling, fire training, food hygiene and first aid. THIS REQUIREMENT REMAINS OUTSTANDING. The Registered Person and Manager must ensure that formal supervision of all staff takes place six times per year. That concerns relating to staff work practice are followed up promptly; records must be kept in individual files for inspection. REQUIREMENT FOR SUPERVISION REMAINS OUTSTANDING. 8th April 2005 and ongoing. 30TH September 2005 30th August 2004 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 Good Practice Recommendations Rosemary Lodge E54 S17019 Rosemary Lodge V225192 080405 Stage 4.doc Version 1.30 Page 30 Commission for Social Care Inspection Birmingham and Solihull Local 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. 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