Inspection on 21/04/06 for Roseneath

This inspection was carried out on 21st April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Roseneath 15/12/08

Roseneath 05/02/08

Roseneath 31/07/07

Roseneath 24/08/05

Roseneath 26/04/05

Roseneath 09/12/04

Roseneath 10/08/04

Roseneath 08/03/04

Roseneath 13/08/03

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

CARE HOMES FOR OLDER PEOPLE Roseneath 163-165 Hamstead Road Handsworth Wood Birmingham West Midlands B20 2RL Lead Inspector Jill Brown Unannounced Inspection 21st April 2006 08:45 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 Roseneath DS0000039328.V289430.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. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Roseneath Address 163-165 Hamstead Road Handsworth Wood Birmingham West Midlands B20 2RL 0121 523 8280 0121 551 5740 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 M Mughal Mrs Rashma Ranni Bhatoe Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That two named people, who are under 65 years of age at the time of admission can be accommodated and cared for in this home. 24th August 2005 Date of last inspection Brief Description of the Service: Roseneath is located on Hamstead Road in a mainly residential area of Handsworth. The home has easy access to public transport and the popular shopping area of Handsworth and community facilities are within five minutes travelling distance from the home. Formerly two large domestic dwellings, the property has been converted into one large care home providing accommodation for up to 30 elderly people. The properties are linked on the ground and first floors and at the front of the home. Bedrooms are located on all three floors of the home, although the majority are on the first and second floors. There are two shaft lifts, one in each property giving service users easy access to all floors. Bedrooms vary in size and some have en-suite facilities. There are two bathrooms on each floor of the home; the two on the ground floor are equipped with hoists for those service users requiring assistance and one on the first floor had a fully assisted shower. There are also numerous toilets throughout the home. On the ground floor there are four lounges, a conservatory, two dining rooms, a large well-equipped kitchen, a laundry, staff facilities and an office. There is also a hairdressing salon within the home, which is located on the first floor. There is ramped access to the front of the home and some parking space. To the rear is a garden with a patio area, shrubs and lawns. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors Jill Brown and Jane Walton conducted an unannounced inspection on day in April over approximately 12 hours. All of the key standards were inspected. Six residents and 2 staff were spoken to as well as the owner and manager of the home. The inspectors looked at a variety of records including the 3 residents care records in depth and one other in parts and 3 staff records. The medication administration records (MAR) were looked and records about the maintenance of services such as gas, electric and lifting equipment. A tour of most of the building was undertaken. The inspectors also looked at the requirement left by visits from West Midlands Fire Service, Food Safety and Health and Safety Departments when they visited the home. The Commission received 9 comment cards from residents and 3 from relatives about the home. What the service does well: The home had kept up to date with all maintenance and inspection required of key services such as lifting equipment, gas and electricity. It was clear the home worked with health professionals to ensure appropriate care for residents. The medication administration was good with few errors and a few adjustments would make this even better. Staff showed a willingness and patience to assist residents that show behaviour that challenges. Residents were very complimentary about the staff. The inspectors saw a staff member assisting a resident to eat and this was done well giving the resident time and talking to her throughout. The staff were aware of how to keep residents safe and a number had been trained in prevention of abuse. The residents enjoy the breakfast meal at the home. Residents knew how to make complaints and they said the owner talked to them daily to ensure that everything was all right. Relatives were happy with the care their resident received. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 6 The home had enough staff on duty at the time of the inspection and the home had achieved a target of 59 of staff qualified to NVQ2 level. It was clear that the home were arranging required training such as moving and handling. What has improved since the last inspection? What they could do better: The home needed to be more consistent in completing assessment forms as this ensures that care planning can be done to meet residents’ needs. They need to discuss any potential admission to the home where the new resident has needs not covered by the home’s certificate of registration. Care plans needed to be in a level of detail that new care staff can give care in the way that meets the health, personal care needs and wishes of the resident. Care plans were not updated with new information. A resident was moved in a wheelchair without footplates in place and this could cause serious injury. Residents’ personal care needs were not always met. Spectacles were dirty, several of the men had not been shaved and it was not clear from the care planning or daily records if this was because residents refused. Residents were involved in some activities but residents spoken to wanted more. There were no individual activity plans for residents that were unable or unwilling to join in group activities. The arrangements for meals were variable. Although residents enjoyed breakfast other meal times were not as good. The menus showed little variety and puddings were limited to cold jelly and ice cream type puddings. Residents that needed specific dietary arrangements did not have these attended to adequately. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 7 The home responds to inspections by other agencies rather than monitoring for itself the upkeep of the home. This needs to be part of the homes quality audit trail. West Midlands Fire Service, Food Safety department and Health and Safety department and the Commission all found areas that needed action. The home had undertaken most of the work required but small items of repair and maintenance that put resident’s at risk need to be identified and put right. Examples of this several lighting units, flooring and vanity units needed repair, the garden paved areas and concrete slopes needed attention and the linen and pillows in a number of bedrooms needed replacement. Information on substances that dangerous to health such as bleaches was not being kept and this gives information on how to care for skin if there is an accidental spillage. The home hadn’t ensured that appropriate checks on staff were kept up to date and that they had kept copies of staff ability to work in the country. The checking of information on staff application forms could be improved. The home did not have a clear chart of the training staff had completed to show inspectors and to plan further training as needed. The home was managed adequately but the lack of a full quality audit system meant that the home failed to meet recommended frequency of staff meetings and supervision, and residents meetings that inform improvements in the home. The Commission is concerned about these continued failings and is monitoring the home to ensure that improvements are sustained and residents’ health and well being is guaranteed. 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. Roseneath DS0000039328.V289430.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 Roseneath DS0000039328.V289430.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 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Whilst the information collected in most areas was good a lack of attention to detail meant that important areas were missed in the planning of residents care. EVIDENCE: The home stated that their fee level is £332-£346 plus an £11 top up. Most residents now have a contract explaining the terms and conditions of their stay and the rest of the residents must have one by the end of their trial periods. Information was collected prior to people being admitted to the home. This information was mostly useful but gaps in completion in records prevented the Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 10 assessments being good. For example records on occasions were not signed and dated by the member of staff completing them and areas such as ethnic origin and religion were not always completed and planning of care therefore did not take place about these needs. In one case a member staff was not clear about the ethnic origin of a resident and this is of concern. Assessments contained information relevant to the needs of the residents. The home has built up a relationship with a number of community services and residents are referred from these services. The home needs to ensure that they check with the Commission if residents have a mental health difficulty so that admissions remain within their category of registration. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 11 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 Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. Care planning was not in enough detail to ensure that good health and personal care was given to residents. Medication administration was good and this protects the health of residents. Residents were treated kindly and sensitively. EVIDENCE: Care plans were not in enough detail to ensure that care was given in a personalised way. Residents that had substantial difficulties including behaviour that challenges did not have details of how these conditions were to be managed in a structured way. Risks such as overeating were given minimal solutions such as three meals a day no snacks. Care plans were not always updated. One situation stated that a resident needed encouragement to eat but that had been when the resident had been unwell. In fact the resident had recently put on 14 pounds in a month. The monthly review for this person Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 12 stated ‘no changes’. There were no reviews in March and April and this was indicative of little management in these months. Personal hygiene needs and assistance to be given was poorly recorded with fairly general statements like ‘encourage to shower’. Moving and handling assessments were not in enough detail to show how residents are to be transferred from place to place safely and in one case was not updated with the current way a person moves from one place to another. Resident records showed that residents were given access to health professionals as their health conditions demanded. Residents, that needed, have assistance from Community Psychiatric Nurses and were reviewed under the Care Programme Approach (CPA). Residents saw opticians, chiropodists and dentists as needed. Residents varied in having their personal hygiene needs met. Several of the men hadn’t been shaved for a number of days. It was clear some of these men might be refusing to be shaved but the home did not record refusals; differing approaches were needed and clear records of when this care had been offered. All residents in one lounge had dirty spectacles. One resident said ‘I don’t like these glasses they are not as good as my other ones’ but when they were cleaned he thought they were fine. Residents were wearing different styles of dress indicative that residents had chosen what to wear. One resident’s difficulty with clothing was recorded in their care plan. The home did not have an undue number of accidents recorded given the number of residents in the home and their difficulties. One incident between two residents was not reported to the Commission as required. A member of staff was seen moving a resident in a wheelchair without footplates in place. The owner had since the last inspection bought two new wheelchairs so this wouldn’t happen. An immediate requirement was left at the time of the inspection about this matter. Medication storage was good. The person administering medication was knowledgeable and had appropriate training in medication administration. It would assist the checks to have a photocopy of the relevant prescription and a photograph of the resident with the Medication Administration Record (MAR). The amount of medication had not been counted when it came in to the home so a check of the number of tablets taken could not be done. It was clear that residents that refuse medication are offered it on several occasions and this is Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 13 good practice. The staff member indicated that the manager undertakes random audits routinely. All the medication that was in a monitored dosage system was correct. Staff demonstrated they knew the residents and were willing to assist residents: - when they wished to go out and, when their illness meant their behaviour could be difficult. The inspectors noticed some good interaction between staff and residents. Residents were generally complimentary about the staff. All residents had received an Easter card and a small toy chick for Easter. It was recommended that in one resident’s bedroom that privacy frosting be placed on the window. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 14 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): 12, 13, 14, 15 Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. The arrangements for activities and meals did not ensure that individual needs were provided for. Residents were given choices about lifestyle and relatives were encouraged to visit and these things improve residents’ lives. EVIDENCE: Residents were assisted to go out when possible; one resident was taken out on the day of the inspection on request. One resident said that they went out to the local park with relatives. The manager and owner said that had had some resistance from residents to going out. There were no individual activity plans on the care files seen. Daily records did not show when residents became involved in activities. Resident meetings records were seen but no outcome was recorded of issues raised at these meetings. One resident’s comment card received stated that the resident wanted more activities to be arranged such as bingo and quizzes. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 15 Relatives were able were allowed to visit when they wished and were happy with the care that residents received. As well as the resident’s bedroom there are several lounges where visits can take place. There were no undue restrictions on residents in the home. Residents moved around the home at will. Residents rose when they wanted and said that they could go to bed when they wanted. Residents’ rooms had important bits of furniture ornaments and so on belonging to the resident, which made the rooms look more homely. One resident said that he had breakfast when he wanted and he could have ‘a full English’ if he wanted or porridge. Another said they had tea and toast in a morning. Residents thought that the tea menu was boring mainly soup and cake. The home’s menu did not detail snacks or type of sandwiches provided. All the food on the menu was traditionally English despite the home having residents from the black and ethnic communities. There was little variety in the individual four-week rotas and choice of puddings was limited with a large dependence on cold puddings such as Jelly and ice cream. One resident requested that there be diabetic snacks available. On the day of the inspection it was noted that some residents had difficulty with the meat and there was few vegetables on offer. The menus did demonstrate how residents attain five portions of fruit or vegetables a day. The kitchen was very well stocked for food. Residents that have their food pureed did not have it done separately so that the resident can enjoy individual tastes. One resident commented they didn’t like their food all mixed up. The inspectors observed a resident being assisted to eat and this was done sensitively and well. The staff member gave time for food to be eaten between spoonfuls and ensured drinks were given. The staff member talked to resident throughout the process in a way that was above just getting the job done and this is commended. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. It was clear that the home tried to ensure that residents were safe and happy with the service they provide. EVIDENCE: The residents spoken to recognised the owner of the home. One said that when he is in he comes to talk to us he asks if there is anything wrong and that they can go to him with any complaints about the home. The home had amended the complaints procedure as requested. The home had regular monthly resident meetings however did not record the how issues raised had been resolved. These meetings did not happen in March or in April up to the time of the inspection. There was evidence that the home had tried to arrange an adult protection training session however this was cancelled and rearranged for a date after the inspection. Staff spoken to were able to respond appropriately to questions about keeping residents safe and had done some abuse training. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 17 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, 24, 25, 26 Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. The home whilst being redecorated and comfortable, in areas had failings that put residents at risk of injury. EVIDENCE: A visit by the Health and Safety department in December outlined several failings of the home in maintaining health and safety in the home. Several of these issues had been addressed by this inspection. Outstanding requirements were: - the painting of slopes in the garden, the relaying of and removal of algae from slabs, and improvement of drainage of puddles to prevent people slipping and tripping. The home said that they were awaiting the better weather to ensure these were completed. One bathroom’s Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 18 lighting was too dim and the requirement for the cellar handrail to be resecured was not looked at this inspection. The lounges in the home were comfortable and well decorated. However the lighting in the home needed attention with several lighting units having bulbs and shades missing. A resident’s toilet needed a toilet seat that fitted it to prevent the resident’s skin being trapped. A number of window restraints needed replacement before being let and one resident’s window needed a restraint immediately fitting. Wardrobes were not fixed to the walls and could be pulled over. There were trip and graze hazards in a number of bedrooms from carpets being wrinkled and vanity units that had rough edges. A number of the bedrooms had small repairs needed that had not been properly addressed. The home was required at the inspection to audit the home and provide an improvement plan to ensure that all these issues were addressed. The home has lovely large clocks throughout. The linen and pillows in a number of bedrooms were looking tired and needed replacement. A bathroom used by at least one resident did not have a call alarm over the bath as well as over the toilet and this means the resident could not gain assistance if they needed it. The home was generally clean and fresh throughout except for a sticky floor near the smoking lounge, however many of the rooms were not let and it is unlikely the one cleaner can manage all the cleaning needs of the full building. The kitchen fridges were registering above the 0-5 degrees centigrade recommended to ensure that food is stored well. There was no liquid hand wash in the kitchen for kitchen staff to wash their hands. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 19 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, 28, 29, 30 Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to the service. Whilst the home was improving in its record keeping and training some areas of management of information and checks were not good enough to ensure residents were protected. EVIDENCE: On the day of the inspection adequate numbers of staff were on duty and residents’ needs were managed well. It was noted from the homes rotas that the cook appeared to be working everyday for the past month and this is not good practice. The home’s pre-inspection questionnaire stated that 59 staff have completed the NVQ2 in care training. There was evidence of training being planned with ‘prevention of falls’ ‘moving and handling’ and ‘protection and abuse’ training occurring in the coming month. Staff records showed that staff were having checks before starting work at the home. All staff files sampled had references and at least a POVA first check. However a number of the existing staffs leave to remain and work in the UK was not found on file. Gaps in staffs work history were not explored and Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 20 references were not always verified. This was of serious concern to the Commission. However the home supplied the staff’s evidence of being able to work subsequent to the inspection. The newer staff had induction records this showed that staff have been given training of how to do the job and been introduced to the residents. The application forms used needed to be improved, as the photocopy available was poor. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 21 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): Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Whilst the home has some outstanding requirements in this area they have improved. EVIDENCE: The manager had yet to complete the required NVQ level 4 in management. It was clear that the home held resident meetings routinely although this had lapsed over the last 2 months. Staff meetings were held irregularly and did not contain information of who had attended and neither the staff nor the resident meetings had recorded that issues raised had been addressed. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 22 The home has started some quality audits such as medication and has meetings with residents but has not ensured a full quality audit trail throughout all of the homes performance. The money of residents was managed in different ways to ensure that residents were guaranteed access to it. A number of residents have their personal allowance sent from the City Council to the homeowner. Records of this money can be seen from the city council and the entry can be seen on residents’ individual accounts. Other resident have money brought in by relatives and the home ensure items such as hair care, residents’ personal purchases and so on are paid for. The home keeps individual receipts. On resident account was not right with the amount of money but the error was found immediately in the account. It is recommended that the records are checked and signed as correct on a weekly basis. Staff supervision had been undertaken but not at the regularity required. The home manager stated this had slipped and staff confirmed this. The home had appropriate checks for maintenance and inspection of lifting equipment, electric and gas services. However the home did not have any COSHH data sheets and this may mean that people that have an accidental spillage on their clothing and skin may not receive appropriate treatment. The homes laundry and hairdressing room would be better serviced by having a number lock on to ensure safety and easy access to staff. The home had responded to requirements made by the West Midlands Fire Service except for training. The home was looking for means of training that would ensure they could guarantee that all staff had fire training twice a year. The home had appropriate gas and electricity inspection certificates and lifting equipment had been inspected and maintained. The home needs to ensure that all improvements are sustainable. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 23 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 3 2 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 3 2 2 X X 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 X 2 Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 24 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 OP3 Regulation 14(1) 12(4)(b) CS Act 2000 24 Requirement Timescale for action 31/05/06 2 OP4 3 OP7 15(1)(2) (b) 4 OP7 15(2)(b) The home must ensure that all key personal details are recorded to ensure appropriate planning takes place. The home must ensure that all 31/05/06 new admissions meet the homes conditions of registration. Where there are any doubts the Commission must be contacted. All service users must have care 31/05/06 plans that clearly detail all their needs and how staff will meet these needs. Previous time scale of 01/02/05 not met. Care plans must show how care is to be given in enough detail to reflect the individuality of the resident. Care plans must be reviewed 31/05/06 monthly and include evidence that the service user or their representative has been party to them. Previous time scale of 01/02/05 not met. Care plans must be updated on the information found at the reviews. DS0000039328.V289430.R01.S.doc Version 5.1 Roseneath Page 25 5 OP7 13(5) 6 OP8 12(1)(a) Manual handling risk assessments must include the details of actions to keep residents safe during transfers and actions to be taken by staff in the event of a fall. Previous time scale of 01/02/05 not met. Clear records must be kept of when residents have been assisted to shave and when they have refused. Residents must have their glasses cleaned routinely. Wheelchairs must not be used without foot rests unless specifically detailed in a care plan. All boxed medications must have the number of tablets written on the Medication Administration Record (MAR) to ensure that the amount of tablets taken can be tracked. There must be clear documentation of how service users are spending their days to evidence their social needs are being met. Previous timescale of 01/02/05 not met. The registered person must ensure that service users are consulted about their preferred leisure activities and that there is a programme of appropriate activities on offer in the home. Those residents not able to join in group activities must have an individual activity plan. Meals provided must reflect what is offered on the menu, have regard to residents likes, culture and nutritional needs The menu must show: More variety Type of sandwiches on offer DS0000039328.V289430.R01.S.doc 05/05/06 31/05/06 7 OP8 13(4)(c) 22/04/06 8 OP9 13(2) 31/05/06 9 OP12 12(1)(a) 31/05/06 10 OP12 16(2)(n) 31/05/06 11 OP15 16(2)(i) 31/05/06 Roseneath Version 5.1 Page 26 12 OP19 23(2)(b) (d) 13 OP22 13(4)(a) (b)(c) 14 OP24 16(2)(c) 15 OP25 23(2)(c) 16 OP26 13(3) Snacks available for both people that need to increase weight and for those that are on a weightreducing programme. Reflect the cultural preferences of the residents Where a resident requires to have food pureed this must be done in a way to preserve individual tastes of food. The homeowner and registered manager must compile a list of all the repairs, refurbishment and replacement (such as linen) to bring the home up to standard. A refurbishment, replacement and repair plan for the whole home must be sent to the Commission. Residents must have access to emergency call points in their bedrooms and bathing and toilet facilities. This remained outstanding since 24/08/05. The manager must ensure that all the furnishings and fittings required by the National Minimum Standards are available in service users bedrooms. Previous timescale of 01/02/05 not met. All lighting in the home must be in working order. Previous time scale of 01/01/05 no met. All food fridges must be adjusted so that the temperature of food stored is above 0 degree centigrade and below 5. The registered manager must ensure that there is liquid hand wash in the kitchen at all times. The registered manager must ensure at all times that staff files have the required evidence to show that staff are able to work DS0000039328.V289430.R01.S.doc 10/05/06 31/05/06 31/05/06 31/05/06 31/05/06 17 OP29 19 Sch 2(7) (8) 05/05/06 Roseneath Version 5.1 Page 27 18 OP29 13(4)(c) 13(6) 19 20 OP31 OP33 10(2)(3) 24 in the home The home must retain evidence that they have explored gaps in employment history and validated references for new employees. The registered manager must completed the Registered Managers Award training by The home must have a quality assurance system that ensures residents’ views on the service can be listened to. 05/05/06 30/09/06 31/07/06 21 OP38 13(3) 22 OP38 23(4)(d) Residents meeting must have show the outcomes on the issues residents have raised with the home. Control of Substances Hazardous 31/05/06 to Health (COSHH) data sheets must be gain for any such products used in the home. As an interim information may be lifted from the containers and kept on a COSHH file. All staff must receive fire training 31/05/06 at least twice a year. Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP2 OP9 Good Practice Recommendations It is recommended that residents receive a contract of the terms and conditions of their stay during the resident’s trial stay. It is recommended that that a photograph of the resident be kept with the MAR. It is recommended that a copy of the prescription relating to the MAR be kept with the MAR these actions provide extra checks to good medication administration. It is recommended that privacy frosting be placed on one resident’s bedroom window. It was strongly recommended that an additional cleaner be employed at the home. It is recommended that all staff have a day off during the working week. It is recommended that residents’ accounts and balances are checked on a weekly basis to ensure they are correct. It is recommended that staff have supervision no less often that six times a year. It is recommended that the homes laundry and hairdressing room doors have a number lock on to ensure safety and easy access to staff. 3 4 5 6 7 8 OP10 OP26 OP27 OP35 OP36 OP38 Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 29 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 Roseneath DS0000039328.V289430.R01.S.doc Version 5.1 Page 30 - 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!