Inspection on 24/08/05 for Roseneath

This inspection was carried out on 24th August 2005.

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

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

Other inspections for this house

Roseneath 15/12/08

Roseneath 05/02/08

Roseneath 31/07/07

Roseneath 21/04/06

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 Road Birmingham B20 2RL Lead Inspector Brenda ONeill Unannounced 24 August 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. Roseneath E54 S39328 Roseneath V243879 300805 Stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Roseneath Address 163-156 Hamstead Road Handsworth Wood Birmingham B20 2RL 0121 523 8280 0121 551 5740 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 M. Mughal Rashma Bhatoe (acting) Care Home 30 Category(ies) of Older People (30) registration, with number of places Roseneath E54 S39328 Roseneath V243879 300805 Stage 0.doc Version 1.40 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. Date of last inspection 26 April 2005 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 assissted 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 E54 S39328 Roseneath V243879 300805 Stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of the statutory visits to this home for 2005/2006 and was unannounced. Two inspectors carried out the inspection over one full day. During the visit a tour of the premises was carried out, two resident and staff files were inspected as well as other care and health and safety records and policies and procedures. The inspectors spoke with eight of the eighteen residents, the acting manager, deputy manager, senior care assistant and one care assistant. What the service does well: What has improved since the last inspection? The home had not had any complaints or adult protection issues raised since the last inspection in April 2005. There was a better recognition of issues concerning the privacy and dignity of the residents, for example, extra funding had been explored so that a resident who was incontinent and spent a lot of time in his room could have an en-suite room instead of him having to walk to the toilet another resident had been moved to a bedroom that was not overlooked as the curtains were often pulled down or not closed. Roseneath E54 S39328 Roseneath V243879 300805 Stage 0.doc Version 1.40 Page 6 The daily records for the residents had improved and included a little more detail of the general well being of the residents. There were appropriate records to evidence that the health care needs of the residents were being met. The acting manager was trying to involve people from the local community in the home and to enable residents to go out more. There was a church visitor who came to the home once a fortnight and would take individuals out if they wished. The acting manager had been in contact with an African befriending service for residents of that culture and they were to visit the home. Another volunteer was also due to visit the home to see if it would be appropriate for them to spend time with the residents and possibly accompany people to the shops. There had been a vast improvement in the cleanliness and hygiene in the home making it safer and more comfortable for the residents. Several areas in the home had also been repainted making it much brighter. The temperature of the water to the shower had been regulated to ensure residents would not scald themselves. What they could do better: There needed to be some meaningful consultation with the residents about such things as the menus and leisure activities. The outcomes of the consultations needed to be acted upon to ensure the home were offering the residents a good variety of food and leisure activities that took into account culture, medical needs, likes, dislikes and preferences. The care plans for the residents needed to be improved so that they detailed all their individual needs and how these were to be met by staff and evidence that residents had been consulted about them. The service users guide needed to be completed and in a format suitable for the current residents and any prospective residents to ensure they had all the information they needed about the home. All residents needed to be issued with a contract at the point of admission to the home so that they knew the terms and conditions of their stay. The recruitment procedures for new staff were very poor and needed to be addressed without delay to ensure the residents were not at risk. All the required checks needed to be undertaken prior to staff commencing their employment. Staff training particularly in relation to induction training was inadequate. Staff must receive induction and foundation training to ensure they are equipped with the skills and knowledge necessary for their roles. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 7 Staff raised some concerns in relation to the communication between themselves and the managers. It was evident this was affecting staff morale and needed to be addressed as eventually it would affect the atmosphere in the home and be to the detriment of the residents. 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 E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 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 Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 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) 1, 2, 3 and 5. The statement of purpose and service user guide were not complete and did not give the residents enough information to enable them to make an informed choice about where they live. The assessment procedure ensured the needs of the residents were known prior to admission to the home. Residents were not being issued with a contract or statements of terms and conditions of residence at the point of admission and therefore would not know the conditions of their stay. EVIDENCE: There was a statement of purpose for the home but it needed to be updated to reflect the current staffing and management arrangements in the home. The acting manager also needed to ensure that it either reflected what was offered in the home or that what was stated was offered, for example, meals to a regular cycle and a planned programme of activities. The service user guide was being updated by the manager but had not been completed and it also needed to be available in format suitable for the residents, for example, large print. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 10 The files of the two most recent admissions to the home were sampled. These evidenced that the acting manager was carrying out assessments on any prospective residents to the home and the documentation used covered all the relevant areas. Social workers were also involved in the admission process where applicable. One of the residents recently admitted to the home was able to confirm that he visited the home prior to admission. There was no evidence that either of the residents recently admitted to the home had been issued with a contract or statement of terms and conditions of residence. This needed to be done at the point of admission so that residents were aware of the terms of their stay including the trial period, fees payable and their room number. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10. The care plans did not include adequate detail of the needs of the individual resident to enable staff to know how to care for them. Residents were not being consulted about how they wanted their care delivered. There were systems in place to identify and minimise any identified risks and health care needs. The systems for the administration of medication were good ensuring the residents medication needs were met. The residents’ rights to privacy and dignity were being upheld. EVIDENCE: Two residents’ files were inspected during this visit. One of the files included a generic care plan in relation to personal care and did not bear any resemblance to the resident in question. It referred to bed baths, turning at night and combing hair. The resident in question was spoken with and observed throughout the inspection and was mobile around the home and would not have required turning or bed baths. The resident in question was male and at one point the care plan referred to ‘her’. There was nothing about the individual’s ability to care for himself, his likes, dislikes, preferences or social needs. The second care plan included a little information about the individual but again there was no specific care plan in relation to his individual needs or what he was able to do himself. When observed and spoken with this resident Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 12 was generally quite independent but did have specific dietary needs and this was not reflected in his care plan. There was no evidence to suggest that the residents had been involved in drawing up their care plans. There were numerous risk assessments for each resident including personal, manual handling, nutritional and tissue viability. These were all up to date and were being reviewed monthly. Where a risk had been identified a plan was documented to reduce the risk. The manual handling risk assessments needed to include information for staff as to what actions they would take in the event of a fall if the resident was not injured. There was evidence on daily records of personal and health care needs being met. This had improved since the last inspection. Health care records were easier to track as they were being documented separately from general daily records. There was evidence of visits from the doctor, referrals to hospital, eye tests and district nurse visits. The resident’s weights were also being monitored. The system for the management of medication was generally well managed with only a minor issue being raised in relation to eye drops not being dated on opening and more than one bottle being used. Several issues were raised at the last inspection in relation to privacy and dignity however these had been resolved at this inspection and there seemed to be more recognition of issues, for example, extra funding had been explored so that a resident who was incontinent and spent a lot of time in his room could have an en-suite room instead of him having to walk to the toilet, another resident had been moved to a bedroom that was not overlooked as the curtains were often pulled down or not closed. Staff addressed the residents appropriately and one resident spoken with confirmed that care staff knocked her bedroom door before entering. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 13 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) 12, 13, 14 and 15. There needed to be some consultation with the residents about their preferred leisure activities and meals. The outcome of the consultations and specific individual needs in relation to culture and health needed to be taken into account when drawing up an activity programme and ongoing menus to ensure the residents needs were being met. EVIDENCE: There did not appear to be any rigid rules or routines in the home and residents were seen spending time in their rooms, in the lounges, chatting to each other and staff. There were friendly relationships between the staff and residents. One of the residents commented he preferred to spend his time in his room reading and listening to music and staff were aware of this and that the domestic fetched him the Irish times newspaper. One of the residents did go out to the local shop. As at the last inspection it was difficult to determine if the social needs of the residents were being met as there was no detail of these in the care plans. The manager stated that activities were offered including crafts, board games, manicures and sing songs however there was no evidence of these in the daily records sampled. On the day of the inspection apart from the television and a staff member sitting with the residents in one of the lounges there was no evidence of any stimulation for residents. The Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 14 acting manager needed to ensure that some meaningful consultation took place with the residents as to what activities they would like and ensure these were carried out wherever possible. It was confirmed by some of the residents spoken with that they could have visitors when they wished. There was a notice asking visitors to avoid meal times if possible and to ring before visiting after the night staff were on duty so that staff would be aware they were coming. The acting manager was trying to involve people from the local community in the home and to enable residents to go out more. There was a church visitor who came to the home once a fortnight and would take individuals out if they wished. The acting manager had been in contact with an African befriending service for residents of that culture and they were to visit the home. Another volunteer was also due to visit the home to see if it would be appropriate for them to spend time with the residents and possibly accompany people to the shops. The residents appeared to be able to make some choices and exercise some control over their lives in relation to what time they went to bed and got up, what they ate and how they spent their time. The bedrooms seen were appropriately personalised to the occupants choosing. For the residents unable to express their views it was difficult to determine how they were enabled to make choices as there was nothing in the care plans or the daily records to evidence this. The comments received from the residents included: ‘ It’s smashing’ ‘ If you didn’t like it couldn’t have something different.’ ‘ Food alright’ ‘Food is o.k.’ ‘Can have a cooked breakfast.’ There were cyclical menus at the home that showed a good variety and offered choices at all meals however from the food records sampled it was evident these were not being followed. The records seen were very repetitious particularly in relation to puddings which were almost always cold and very simple to prepare. There was no evidence to suggest that medical or cultural diets were being catered for. As with the activities there needed to be some consultation with the residents about the menus and menus drawn up taking into account the outcome of the consultation to include consideration of medical and cultural diets. Food stocks in the home were good and varied and repetition was not necessary. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 15 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 and 18 Residents were confident that any complaints would be addressed by the home. The complaints procedure needed to be amended to ensure complainants knew they could refer a complaint to the CSCI at any point. There were processes in place for protecting the residents from abuse and the majority of staff had received training in adult protection issues. The home’s procedures for adult protection needed to be amended to ensure the correct reporting procedures were in place and that they complied with the multi agency guidelines. EVIDENCE: There was a complaints procedure in the home however it needed to be amended to ensure that complainants were aware that they could refer a complaint to the CSCI at any time. The home had had one complaint since the last inspection. This was raised during a resident’s review and was in relation to missing clothing and a missing bible. It appeared that these issues had been addressed and the social worker had written to the complainant however the acting manager stated that the issues over clothing were ongoing and she was attempting to resolve them. No complaints had been lodged with the CSCI since the last inspection. The residents spoken with stated they would have no hesitation in raising any issues with the manager or the staff and felt confident they would be resolved. No issues in relation to adult protection had been raised at the home or with CSCI in relation to adult protection since the last inspection. Risk assessments in the home documented strategies for managing identified risks and these appeared to be being followed by staff at the time of the inspection. The acting Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 16 manager needed to ensure she obtained a copy of the multi agency guidelines for adult protection and that the home’s policies and procedures were in line with this to ensure staff followed the correct procedure in the event or suspicion of abuse. The majority of the staff had received training in adult protection issues. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 24, 25 and 26. There had been a vast improvement to the cleanliness and the systems for infection control making the home safer for the residents. Some issues needed prompt attention to ensure residents and staff were not put at risk. There had been further improvements to the general décor and furnishings in the home and it provided a comfortable, spacious environment for the residents. EVIDENCE: There had been no changes to the location or the layout of the home since the last inspection which were suitable for its stated purpose. The home was generally safe, accessible and well maintained. Numerous issues were raised at the last inspection in relation to general maintenance, cleanliness, infection control and safety of the residents. The majority of these had been addressed and there had been a marked improvement in the cleanliness and infection control systems in the home making it safer for the residents. All the lighting and emergency call points that were tested were working, broken furniture had been removed, all the water temperatures tested were at an acceptable Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 18 temperature and fire exits were clear. There had been some further redecoration and new curtains had been ordered for the lounges. Some of the issues that were raised at this inspection were addressed immediately including, padlocks on two fire exits, fire doors being wedged open and an overloaded electrical socket. Issues to be addressed were: • • • • • • The magnetic closures on the fire doors needed to be checked, as some were not closing properly. The privacy lock on the toilet by the conservatory needed to be replaced as it had been removed. The fan in toilet one needed cleaning. Wheelchairs were still being used without footrests. Not all call points could be accessed from beds, toilets, bathing and showering facilities. The numbers showing on the panel of the call system did not always correspond with the numbers on the doors. To ensure staff knew where the call was coming from a table needed to be put by the call panel to indicate what rooms the numbers related to avoid any undue delay in responding to the residents. The vinyl flooring in room 46 needed to be replaced as it had a lot of burn marks in it and it had begun to tear. • The majority of the occupied bedrooms were inspected and were seen to be comfortable and generally well furnished. Residents could have keys to their rooms if they wished and most also had a lockable facility. The acting manager needed to ensure that all the furnishings and fittings in the bedrooms were audited against the National Minimum Standards and ensure all that was required was available. If any resident chooses not to have any item of furniture this must be documented in their file. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 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 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 and 30. Appropriate staffing levels were being maintained but new staff were not receiving adequate training to ensure they were equipped with the necessary skills and knowledge to fulfil their roles. Recruitment procedures were very poor, appropriate checks were not being carried out potentially leaving residents at risk. EVIDENCE: The staffing levels at the home were being maintained at two or three care assistants plus a senior member of staff and two waking night staff, the manager’s hours were not included in the care rota, there was also a cook and a domestic assistant employed. A second domestic had been employed but had left and the acting manager was to recruit again. The staffing levels were adequate as there were only 18 residents in the home at the time of the inspection. There had been little staff turnover since the last inspection and the home had retained a core group of staff which was good for the continuity of care for the residents. Without exception the residents spoken with were positive about the staff group and the help they received. New staff had been appointed in preparation for some staff reducing their hours as they were returning to college and the acting manager was also trying to appoint some more male care assistants to reflect the ratio of male residents. The recruitment records for three staff were inspected. As at the last inspection these were found to be wholly inadequate. There was no evidence of current CRB or POVA first checks, dates on application forms and references Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 20 did not correspond, there was no proof of the eligibility of staff to work in this country, gaps in employment had not been explored and it was not always evident as to who the referees were. This is an ongoing issue at the home and a letter of serious concern was sent to the proprietor following the inspection. The induction training for the new staff was not adequate. For one there were no records at all, the other two had an induction checklist that was carried out on one day but there was no evidence of any ongoing training and one had signed to say they had received and read some of the policies and procedures. The registered person must ensure that all staff receive induction and foundation training as laid down by the Learning Skills Council to ensure they are equipped with the appropriate knowledge and skills to fulfil their work role. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 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 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, 36, 37 and 38. The acting manager had made some improvements to increase the safety of the residents and staff. Further improvements were needed to ensure residents and staff were not put at risk. Communication within the staff team needed to be improved before it became detrimental to the residents. There needed to be effective ways of monitoring and improving the service based on seeking the views of the residents. EVIDENCE: The acting manager had been in post since April of this year. She is a registered nurse and has a lot of experience in the care of older people. She demonstrated a good knowledge of the needs of the residents in her care and had made several improvements in the home particularly in relation to cleanliness, infection control and risk assessments for the residents. She had enrolled on the Registered Manager’s Award training and was due to Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 22 commence in September. An application for her registration as the registered manager had been received by the CSCI and was being processed. Staff raised some concerns in relation to the communication between themselves and the managers. It was evident this was affecting staff morale and was discussed with the acting manager. Issues raised included, lack of two-way communication and staff not being consulted over issues, issues of confidentiality, short notice for meetings and the arrangements for being on call. Clearly these issues needed to be addressed as eventually they will affect the atmosphere in the home and be to the detriment of the residents. There was no evidence of a system of staff supervision and this would be one way of opening up channels of communication on a one to one basis. The acting manager was made aware of how important it was to improve the recruitment procedures for new staff and ensuring they were appropriately trained. There was no evidence of consultation with the residents about issues such as activities, meals or the running of the home. Residents meetings were not taking place. The registered person must ensure that there are systems in place for monitoring the quality and the ongoing improvement of the service based on seeking the views of the residents. Some of the policies and procedures sampled needed to be amended, for example, adult protection and complaints. The reporting of accidents and incidents to the CSCI via regulation 37 had improved since the last inspection. The management of health and safety had improved in relation to cleanliness, infection control and the environment in general. There was evidence on site of the servicing of the majority of the equipment except the bath hoists however these had been taken out of use and the service had been arranged. Issues raised related to the in house checks on the fire alarm and emergency lighting, fire training for staff was out of date and the fire risk assessment needed to be reviewed. Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION 2 3 2 2 x 2 3 3 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 1 1 x x 1 2 2 Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 24 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 1 Regulation 5(1) Requirement The registered person must ensure the home has a service user guide as detailed in Regulation 5 of the Care Homes Regulations and that each resident is provided with a copy. The service user guide must be available in a format suitable for the residents. (Previous timescales given 01/02/05 and 01/06/05 not met.) The statement of purpose must be updated and include all the information as detailed in schedule 1 of the Care Homes Regulations 2001 and reflect what is offered in the home. (Previous time scales given 01/02/05 and 01/06/05 not met.) All residents must be issued with a contract or statement of terms and conditions of residence that contains all the relevant details at the point of admission to the home. (Previous time scales given 01/02/05 and 01/06/05 not met.) All residents must have care plans that clearly detail all their needs and how they will be met Timescale for action 01/10/05 2. 1 4(1) schedule 1 01/10/05 3. 2 5(1)(b) 01/10/05 4. 7 15(1)(2) (b) 01/10/05 Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 25 5. 7 13(5) 6. 9 13(2) 7. 12 12(1)(a) 8. 12 16(2)(n) 9. 15 16(2)(i) 10. 16 22(1) by staff. Care plans must be reviewed monthly and include evidence that the resident or their representative has been party to them. (Previous time scales of 01/02/05 and 01/06/05 not met) Manual handling risk assessments must include the details of actions to be taken by staff in the event of a fall. (Previous time scales of 01/02/05 and 01/06/05 not met.) All eye drops must be dated on opening and discarded after 28 days. Only one bottle must be in use for each resident. There must be clear documentation of how service users are spending their days to evidence their social needs are being met. (Previous timescales of 01/02/05 and 01/06/05 not met.) The registered person must ensure that service users are consulted about their preferred lesiure acativities and that there is a programme of appropriate activities on offer in the home.(Previous time scale given 01/06/05 not met.) After consultation with the residents menus must be drawn up that provide suitable, wholesome and nutritious meals and take into account the medical and cultural needs of the residents. The complaints procedure must be amended to ensure it is clear to complainants that they can refer a complaint to the CSCI at any point. (Previous timescales of 01/02/05 and 01/06/05 not met.) 01/10/05 14/09/05 01/10/05 01/10/05 01/10/05 01/10/05 Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 26 11. 18 13(6) 12. 13. 14. 15. 19 21 21 22 13(4)(a) (b)(c) 23(2)(b) 23(2)(d) 13(4)(a) (b)(c) 16. 22 13(4)(a) (b)(c) 17. 22 13(4)(a) (b)(c) 16(2)(c) 16(2)(c) 18. 19. 24 24 20. 28 18(1)(a) The registered person must ensure the adult protection procedure is consistent with the multi agency guidelines and National Minimum Standards for adult protection. (Previous timescale of 14/01/05 and 01/06/05 not met.) The fire doors on magnetic closures must be checked to ensure they close when released. The privacy lock on the toilet by the conservatory must be replaced. The extrator fan in toilet 1 must be cleaned. Wheelchairs must not be used without foot rests unless specifically detailed in a care plan. (Previous time scale of within one hour not met.) Residents must have access to emergency call points in their bedrooms and bathing and toilet facilities. (Previous time scale of 01/06/05 not met.) There must be a table by the emergency call panel indicating what rooms the numbers relate to. The vinyl flooring in room 46 must be replaced. The registered person must ensure that furnishings and fittings in the bedrooms are audited against the National Minimum Standards and arrangements made to provide any that are missing. If any resident does not require all the furnishings this must be documented in their file. (Previous time scales of 01/02/05 and 01/07/05 not met.) A minimum of 50 of care staff must be qualified to NVQ level 2 or equivalent by 2005. (Previous 01/10/05 25/08/05 01/10/05 01/10/05 25/08/05 01/10/05 01/10/05 01/10/05 01/11/05 31/12/05 Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 27 21. 29 19 schedule 2. 22. 30 18(1)(a) 23. 24. 31 32 9(2)(b)(i) 12(5)(a) 25. 33 24 time scale of 01/06/05 not checked for compliance at this visit.) Staff must not be employed prior to all the required recruitment checks taking place as detailed in Schedule 2 of the Care Homes Regulations 2001.(Previous time scale of 27/04/05 not met.) A letter of serious concern was sent to the proprietor in relation to this. All staff must have induction and foundation training as laid down in the specifications by the Learning Skills Council and completed in the given time scales. A record of all training must be maintained. The manager must be qaulified to NVQ level 4 in management or equivalent. The registered person must ensure there are effective communication channels between managers and staff and vice versa. The issues raised during the inspection must be resolved. The registered person must ensure that there are systems in place for monitoring the quality and the ongoing improvement of the service based on seeking the views of the residents. All staff must receive supervision at least six times peryear. Fire training must be updated for all staff. The fire alarm must be tested weekly and records maintained.(Previous time scales of 10/12/04 and 27/04/05 not met.) The emergency lighting must be checked monthly and records maintained. 01/09/05 and ongoing. 01/10/05 and ongoing. 31/12/05 01/10/05 01/10/05 26. 27. 28. 36 38 38 18(2) 23(4)(d) 23(4)(c) (iv) 01/11/05 07/09/05 25/08/05 29. 38 23(4)(c) (iv) 25/08/05 Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 28 30. 38 23(4)(c) (v) The fire risk assessment must be reviewed. (Previous time scale of 01/06/05 not met.) 31/08/05 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 Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & 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. Extracts may not be used or reproduced without the express permission of CSCI Roseneath E54 S39328 Roseneath V243879 240805 Stage 4.doc Version 1.40 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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