Inspection on 26/04/05 for Roseneath

This inspection was carried out on 26th April 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 24/08/05

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 B20 2RL Lead Inspector Brenda ONeill Unannounced 26th 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. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Roseneath Address 163-165 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 Vacant. Care Home 30 Category(ies) of Old age, not falling within any other caegory registration, with number (30) of places Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: That the two named people, who are under sixty five years of age at the time of admission can be accommodated and cared for in this Home. Date of last inspection 09/12/04 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 CS0000039328.V221098.R01.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out over eight hours by two inspectors and the first of the statutory visits for 2005/2006. During this inspection a tour of the premises was carried out, three resident and staff files were inspected as well as other care and health and safety records. The inspectors spoke with five of the nineteen residents, the proprietor, two senior care staff and one care assistant. At the previous inspection in December 2004 serious concerns were raised over the management of the home and the protection of the service users. Admissions to the home were restricted by the CSCI and two enforcement notices were issued. The notices were in relation to financial records and the medication administration system. Three further visits were made to the home, prior to this inspection, to check on the progress made to the outstanding requirements and compliance with the notices. At a visit made in February the inspectors were satisfied that the home had complied with the notices and at the end of March the restriction on admissions to the home was lifted. What the service does well: What has improved since the last inspection? The assessment process for new residents had improved to try and ensure the home could meet their needs. There were more in depth care plans and resident’s risk assessments had improved. The food stocks and the variety on the menus had greatly improved since the last inspection. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 6 The system in place for managing resident’s personal allowance was much improved with all the required written documentation being available. Several minor repairs had been carried out since the last inspection and there had been some redecoration, the furniture had been replaced in one of the lounges and some of the bedrooms had had new wardrobes. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 7 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 CS0000039328.V221098.R01.doc Version 1.20 Page 8 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) 3,4 and 5. The assessment procedure had improved however it needed to be consistent to ensure staff knew the needs of the residents at the time of admission. Staff at the home were not meeting the documented needs of some residents. EVIDENCE: There had not been any new admissions to the home since the last inspection however the inspector did see the assessment documentation for two prospective residents. One of these individuals was due to be admitted the same week as the inspection and his assessment had been very thorough with evidence of him visiting the home and of staff visiting him to assess his needs. There was also written evidence of the involvement of the relevant professionals. The other assessment did not include sufficient detail about the individual’s needs, for example, it stated a difficulty with communication but did not detail what the difficulty was. The home did not demonstrate to the inspectors that they were meeting the needs of some of the residents. One resident who had mental health needs was clearly unwell at the time of the inspection. Staff were able to tell the inspectors in great detail of how the individual’s mental health needs were Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 9 presenting and there were detailed actions to be followed on the resident’s file under these circumstances. These clearly had not been followed. Also the individual’s daily records did not reflect what the inspectors were told or what they observed during the inspection. Another resident’s file included a risk assessment for pressure care which stated a pressure cushion was to be used and the person was to stand two hourly. It was evident from the observations made that the risk assessment was not being followed. The individual that was due to be admitted to the home had mobility problems and had chosen a particular bedroom. At the time of the inspection the lift on this side of the home was out of order and therefore this person would not be able to access that room. The home could not meet his needs at that time but no contact had been made with him in relation to this. Roseneath CS0000039328.V221098.R01.doc Version 1.20 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, and 10. There had been some progress in relation to care planning and risk assessments however some of these were not being followed by staff therefore placing residents at risk. The systems for the administration of medication were good. The arrangements for personal care did not always ensure the privacy and dignity of the residents was upheld. Residents’ health care needs were not fully met by the home placing some residents health care at risk. EVIDENCE: Three resident’s files were inspected during this visit. Some progress had been made in relation to care planning and risk assessments. Two of the files sampled had quite detailed care plans in relation to physical care needs however there was nothing in relation to social care needs, likes, dislikes and preferences. One file did not include a care plan. There was no evidence to suggest that the residents had been involved in drawing up the care plans or that they were being reviewed on a monthly basis. There were risk assessments on all the files inspected for manual handling, personal risks, tissue viability and nutrition. Manual handling risk assessments did not detail the action to be taken by staff in the event of a fall. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 11 One risk assessment seen for pressure care was not being followed by staff. The daily records for another resident evidenced that his risk assessment in relation to alcohol consumption was not always followed. There was some evidence on daily records of basic health care needs being met including chiropody and visits from the district nurse. Health care records were difficult to track as they were not always recorded on the medical visits sheets but amongst the daily records. Where more specialised health care needs had been identified these were not always being met appropriately, for example mental health specialists had not been involved for one resident. Another resident had had a visit from the physiotherapist as his mobility had been an issue since a fall but there was no detail of the outcome of the visit. Resident’s weights were being monitored on a monthly basis. The general well being of the residents was being recorded on a daily basis but after discussions with staff it was evident these records did not always reflect the true picture. Staff needed to ensure that these records were explicit and factual. Also the use of words such as ‘bad mood’ needed further explanation as staff could have interpreted these very differently. There had been further improvements to the medication system since the last inspection which was very well managed. No discrepancies were found in the records. All the staff who administered medication had received accredited training. The inspectors had some serious concerns in relation to the privacy and dignity of the residents. One of the residents informed the inspectors that he used a urine bottle in one of the communal areas instead of being taken to the toilet. Not only is this an infringement of his privacy and dignity but also very embarrassing for other residents who use this area. Several residents looked very unkempt. When asked about this staff commented that some residents would not have a shave or a hair cut and said that records were kept to demonstrate staff had tried to address this however the inspectors found only one comment in the daily records inspected in relation to this. Roseneath CS0000039328.V221098.R01.doc Version 1.20 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) 12 and 15 Resident’s interests were not recorded and there was no evidence of opportunities for stimulation through leisure and recreational activities in the home. There had been a vast improvement in the meals which were good offering both choice and variety to residents. EVIDENCE: There did not appear to be any rigid rules or routines in the home and residents were seen spending time in the lounges, dining areas and in their bedrooms. There were evident friendly relationships between staff and residents and all residents spoken with stated staff were helpful and kind. 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. Daily records seen did not evidence any social activities apart from watching television and chatting. On the day of the inspection the hairdresser was in the home and a member of staff was sitting with the residents in one of the lounges other than this there was no evidence of any other stimulation for residents. The televisions were on in three of the lounge areas, during the afternoon one had children’s programmes on which was totally inappropriate as they had not been chosen by residents. There had been a vast improvement in the food on offer to the residents since the last inspection. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 13 The menus seen were varied and offered choices, food stocks in the home were good with evidence of fresh fruit and vegetables being available. All residents spoken with were happy with the meals they were receiving. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 14 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) 18 The processes in place for protecting residents from abuse had improved since the last inspection and staff had received training in adult protection issues however they were not always following the documented risk assessments for the residents. EVIDENCE: The policies and procedures for adult protection were not inspected during this visit therefore the requirement carried forward at the previous inspection has been brought forward to this report. At the last inspection there were major concerns in relation to adult protection and the lack of recognition by staff of adult protection issues. Since that inspection all staff had received training in adult protection, several residents had been reassessed due to their challenging behaviour and two had moved. This had enhanced the safety of the remaining residents. The process of risk assessing residents and documenting strategies for managing risks had improved however it was apparent from the practices observed and from daily records that the risk assessments were not always followed and this did not ensure the well being of the residents. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 15 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 some improvement to the general décor and furnishings in the home however the systems for infection control and maintaining the cleanliness of the home were inadequate making the environment potentially unsafe. EVIDENCE: There had been no changes to the location or the layout of the home since the last inspection which were generally suitable for its stated purpose. Some improvements had been made since the last inspection including some general redecoration to bedrooms and the two ground floor bathrooms, some new furniture had been purchased for one of the lounges and some new wardrobes had been purchased. The majority of the general repairs highlighted at the last inspection had been carried out. During the tour of the premises at this inspection numerous issues arose in relation to repairs, safety, cleanliness and infection control including: Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 16 • Several areas of the home were below an acceptable standard of cleanliness including numerous carpets, light switches, curtain rails, washing baskets, and some wash hand basins. One resident had his lunch on a very dirty tray. • One fire door was blocked with a clothes airer. • There was a broken chair in the smoking area which residents could have fallen through had they sat on it. The other furniture and the flooring in the smoking area were in a poor state of repair. • There were curtains missing from two of the lounge areas. • The underside of one of the bath chairs was in need of thorough cleaning. • Several of the call points tested in the bedrooms were not working and some residents did not have access to the call system from their beds. • The inspectors observed a wheelchair being used without footrests which could have led to the injury of the resident. • Several items of broken furniture were observed in bedrooms. • The flooring in room 46 needed to be sealed and made safe. • Several of the overbed lights were not working and some of the other lighting in corridors was not working. • The temperature of the water to the first floor shower and the en-suite shower were excessively high. • Odour control in two of the lounges and some of the bedrooms was poor. • Liquid soap and disposable towels were not available in any of the communal toilets or bathrooms or the laundry. • Staff did not always wear protective clothing appropriately. • There were some very badly stained commode pots. • Not all COSHH substances were stored securely. The registered person needed to have cleaning schedules in place to ensure all areas of the home were kept reasonably clean and the risk of infection kept to a minimum. It was strongly recommended that as the building is so large that an additional cleaner be employed and someone delegated to oversee the cleaning. Bedrooms varied in size and residents were able to have keys to their bedroom doors if they wished. The manager needed to ensure that, in consultation with residents, the minimum requirements for furnishings and fittings as detailed in the National Minimum Standards were met as not all of the bedrooms met this standard. There were 11 empty bedrooms at the time of the inspection and none were ready for occupation either due to cleanliness or because items had not been removed that belonged to the previous occupants. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 29 Minimum staffing levels were being maintained with a stable staff group which was very good for continuity of care. Recruitment procedures were very poor, appropriate checks were not being carried out potentially leaving residents at risk. EVIDENCE: The rotas in the home evidenced that the minimum staffing levels of three care assistants plus a senior care were being maintained in the home. The home also employed a cook and a cleaner. The care staff group had remained stable since the last inspection with no staff turnover. The inspector checked the recruitment records for the newly appointed handyman and one care assistant. These were found to be wholly inadequate. It appeared that the references for the care assistant had been taken after appointment and there were no references for the handyman. The application form for the handyman was not fully completed and although the CRB check had been sent for no POVA first check had been undertaken. This person had access to all areas of the home and all residents and staff and therefore needed all the checks detailed in Schedule 2 of the Care Homes Regulations to be in place prior to him commencing employment. Training was not assessed during this inspection therefore the requirements made following the last inspection have been brought forward to this report. Roseneath CS0000039328.V221098.R01.doc Version 1.20 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, 35, 37 and 38. The home was in need of a stable management team that could offer guidance and direction to the staff to ensure the health, safety and welfare of the residents. EVIDENCE: There was no registered manager at the home and there has not been since the present proprietor took over. The previous manager left the home very abruptly after numerous issues of concern were raised. A temporary manager was appointed and although she has made improvements to the care planning, risk assessments and financial records in the home several other areas need further improvement. At the time of this inspection the deputy manager had also left the home. A new manager had been appointed but was on leave at the time of the inspection. The home was in need of a stable management team that could offer guidance and direction to the staff to ensure the health safety and welfare of the residents. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 19 The registered person must appoint an appropriately qualified manager and seek registration from the CSCI. The financial records for residents were inspected and were found to be acceptable. There were records of all monies being handled for residents, receipts were available for expenditure and two staff had signed the records where residents were unable to sign. The majority of the records checked were up to date but care plans needed further development and daily records needed to accurately reflect the well being of the residents. The inspector was made aware that one of the lifts was out of order at the time of the inspection and had been for some time. The repair for this was in hand however the CSCI should have been notified of this as detailed under Regulation 37 of the Care Homes Regulations. This undoubtedly affected the well being of the residents as some had had to change their bedrooms as they could not manage the stairs. It also appeared from earlier daily records that one of the residents had had to stay in his bedroom as the lift had been out of order. Numerous issues were raised during this inspection in relation to health and safety and several immediate requirements were left with the proprietor. The majority of these are detailed in this report under environment. There was evidence on site of the servicing of all equipment and that the water system had been checked for the prevention of legionella. The weekly fire alarm checks were not up to date and the fire risk assessment was in need of review. Roseneath CS0000039328.V221098.R01.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 1 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 2 1 3 1 2 1 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 1 x x x 3 x 2 1 Roseneath CS0000039328.V221098.R01.doc Version 1.20 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 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 Service user is provided with a copy. (Previous timescale given 01/02/05 not assessed for compliance at his visit.) The statement of purpose must be updated and include all the information as detailed in schedule 1 of the Care Homes Regulations 2001. (Previous time scale given 01/02/05 not assessed for compliance at this visit.) The home’s contract must be amended to ensure it contains all the relevant details. (Previous timescale given 01/02/05 not assessed for compliance at this visit.) The registered person must ensure there is a full assessment of any prospective residents needs prior to admission to the home. The registered person must ensure that all the documented needs of the residents are met. Timescale for action 01/06/05 2. 1 4(1) schedule 1 01/06/05 3. 2 5(1)(b) 01/06/05 4. 4 14(1)(a) (b) 01/06/05 5. 4 12(1)(a) (b) 01/06/05 Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 22 6. 7 15(1)(2) (b) 7. 7 13(5) 8. 7 13(4)(c) 9. 8 12(1)(a) (b) All service users must have care plans that clearly detail all their needs and how they will be met by staff. Care plans must be reviewed 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) Manual handling risk assessments must include the details of actions to be taken by staff in the event of a fall. (Previous time scale of 01/02/05 not met.) The registered person must ensure that all documented risk assessments are followed by staff. There must be documented evidence that all health care needs have been followed up appropriately. Records of visits by health care professionals must be documented in such a way that they can be easily tracked. Daily records must accurately reflect the well being of the residents. 01/06/05 01/06/05 26/04/05 14/05/05 10. 8 12(1)(a) 01/06/05 11. 10 12(4)(a) 12. 13. 10 12 12(4)(a) 12(1)(a) Daily records must be explicit to ensure all staff are clear as to what they mean. The registered person must 26/04/05 ensure that the privacy and dignity of all residents is maintained at all times. Urine bottles must not be used in 26/04/05 communal areas. There must be clear 01/06/05 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.) Version 1.20 Page 23 Roseneath CS0000039328.V221098.R01.doc 14. 12 16(2)(n) 15. 16 22(1) 16. 18 13(6) 17. 19 23(2)(d) 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. 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 timescale of 01/02/05 not checked for compliance at this visit) 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 not checked for compliance at this visit) All parts of the home must be kept to an acceptable level of cleanliness. (Previous time scale of 16/12/04 not met.) Cleaning chedules must be put in place to ensure all areas of the home are kept reasonably clean. 01/06/05 01/06/05 01/06/05 29/04/05 18. 19. 20. 21. 22. 23. 24. 19 20 20 20 21 22 22 13(4)(a) (c) 13(4)(a) (b)(c) 16(2)(c) 16(2)(c) 13(3) 13(4)(a) (b)(c) 13(4)(a) (b)(c ) All fire exits must be kept clear at all times. The broken chair must be removed from the smoking area. The flooring and furnichings in the smoking area must be replaced. All lounges must have curtains at the windows.(Previous time scale of 14/01/05 not met.) The underside of the bath seat must be thoroughly cleaned. All emergency call points must be in working order. Residents must have access to emergency call points in their Within one hour. Within 2 hours. 01/07/05 01/06/05 27/04/05 29/04/05 01/06/05 Page 24 Roseneath CS0000039328.V221098.R01.doc Version 1.20 25. 22 13(4)(a) (b)(c) 13(4)(a) (b)(c) 23(2)(b) 16(2)(c) 26. 27. 28. 24 24 24 29. 30. 31. 32. 25 25 26 26 13(4)(a) (b)(c) 23(2)(c) 16(2)(k) 13(3) 33. 34. 35. 36. 26 26 26 28 13(3) 13(3) 13(3) 18(1)(a) 37. 29 19 schedule 2 bedrooms and bathing and toilet facilities Wheelchairs must not be used without foot rests unless specifically detailed in a care plan. The flooring in room 46 must be made safe. Any items of broken furniture in bedrooms to be repaired or replaced. The manager must ensure that all the furnishings and fittings required by the National Minimum Standards are available in service user’s bedrooms. (Previous timescale of 01/02/05 not met.) All hot water outlets accessible to service users must be restricted to 43 degrees. All lighting in the home must be in working order.(Previous time scale of 01/01/05 no met.) All areas of the home must be kept odour free. There must be liquid soap and disosable towels available in all communal facilities and the laundry. All COSHH must be locked away when not in use. All commode pots must be thorouhgly cleaned. Staff must wear protective clothing as appropriate and change it as necessary. A minimum of 50 of care staff must be qualified to NVQ level 2 or equivalent by 2005. (Previous time scale of April 2005 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 Within one hour. 27/04/05 01/06/05 01/07/05 29/04/05 27/04/05 01/06/05 Within one hour. Within one hour. 27/04/05 27/04/05 01/06/05 27/04/05 Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 25 Regulations 2001. 38. 31 9(2)(b)(i) The registered person must ensure that the manager in post has the necessary skills, experience and qualifications to run the home and that an application for registratio is submitted to the CSCI. The registered person must ensure that the CSCI is notified of any events in the home that affect their well being as detailed under Regulation 37 of the Care Homes Regulations 2001. (Previous time scale of 10/12/04 not met.) The fire alarm must be checked on a weekly basis and records mainatined. (Previous time scale of 10/12/04 not met.) The fire risk assessment must be reviewed. 01/06/05 39. 37 37 01/06/05 40. 38 23(4)(c) (v) 23(4)(a) 27/04/05 41. 38 01/06/05 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 19 Good Practice Recommendations It was strongly recommended that an additional cleaner be employed at the home. Roseneath CS0000039328.V221098.R01.doc Version 1.20 Page 26 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 CS0000039328.V221098.R01.doc Version 1.20 Page 27 - 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. 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