Inspection on 31/07/07 for Roseneath

This inspection was carried out on 31st July 2007.

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 21/04/06

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 Mrs Amanda Hennessy Key Unannounced Inspection 31st July 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 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.V344685.R01.S.doc Version 5.2 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 5741 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 Miss Gillian Goode Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home may accommodate one named service user under 65 years. That the home may accommodate one named service user over 65 years with mental disorder (MD(E)). 8th September 2006 Date of last inspection Brief Description of the Service: Roseneath is located on Hamstead Road in a mainly residential area of Handsworth. The home was formerly two large houses that have 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 residents easy access to all floors. Residents all have their own room 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 residents 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. 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. There is ramped access to the front of the home and some parking spaces. To the rear is a garden with a patio area, shrubs and lawns. The home stated that their fee level is £352.59 plus a £10 top up. Non NHS chiropody, hairdressing and newspapers are not included in the fee but are available within the home at an additional charge if required. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection undertaken without any prior notice by one Inspector between 11.00 and 18.45. The inspection included a tour of the building, talking to service users, relatives, staff and the Manager, a review of records including information forwarded by the Manager before the inspection. Care records were reviewed as part of the “case tracking” of three people who live at the home. Four staff files were also reviewed. Fifteen of the previous twenty-two requirements have been addressed, or removed as they are no longer applicable. Seven new requirements were made as a result of this inspection. The home was given an immediate requirement to ensure that there is sufficient hot water at the home. The proprietor was also asked to forward proposals to ensure that adequate and sufficient assisted baths and showers are provided at the home to meet peoples needs. What the service does well: The home has an experienced manager and good proportion of qualified care staff. Staff are knowledgeable and are able to diffuse challenging incidents and have good understanding of the conditions that affect people who live at the home. Residents are spoken to in a clear, calm and professional manner. Residents have freedom of movement within the home. A number of residents preferred to spend time in their room and this was respected. The Manager and staff are aware of the routines of particular residents and their inability to wait for some things and how they can refuse care on occasions and actions the staff need to take. The home has a plan of activities and it was nice to see residents enjoying the activities with care staff during the inspection. The staff and the manager are clear about practices that may be abusive. The home has issued all staff with the General Social Care Council’s Code of Practice. Incidents that may cause concern are reported to the Commission without delay. Money managed on behalf of residents is managed in differing ways to help the resident. A number are given all their personal allowance others have services such as hairdressing, activities and chiropody paid for out of their money. The management of residents’ money is safe. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some areas of the home have been refurbished and these rooms are pleasant and comfortable. Sadly the refurbishment has taken some time and there is a need to continue with it in a more timely and proactive manner and to ensure that areas awaiting refurbishment are also kept clean. The home has insufficient assisted baths for the number of residents, with just one bath being able to be used at the time of the inspection. Hot water was also found to be insufficient and an immediate requirement was made for this to be addressed. There have been recent aggression outbursts by people who have challenging mental health needs when other residents have been harmed, although these residents have since moved from the home. People who have challenging mental health problems and can be unpredictable may frighten or hurt other vulnerable residents. The registered people must urgently review the home’s registration status to ensure that it only accommodates people with needs for which the home is registered and where it is is able to keep residents safe. The home does have a complaints procedure but this needs to be prominently displayed at the home, to give a prompt so that people know how to raise any concerns that they may have. There is a need for a quality assurance system. A quality assurance system would give the home direction and ensures that residents and relatives views are listened to, and identify ways that the home can improve and develop. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 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.V344685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not move into the home without their needs being assessed. The home accommodates some people who it is not registered to care for, and whose needs are not always met. EVIDENCE: People have an assessment of their needs before coming to live at the home which is undertaken by the home manager. Information obtained from the assessment of their needs is then incorporated into the plan for their care. The Manager writes to the prospective resident confirming that the home will be able to meet their needs. Files seen also contained a record of the terms and conditions of living at the home with information such as the room they will occupy and the amount and what is included by the fee. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 10 The home has six residents with mental health needs and an additional five people with dementia and two with previous alcohol dependency, although the home is not registered to accommodate these needs. There have been recent aggression outbursts by people who have challenging mental health needs when other residents have been harmed, although the aggressive residents have since moved from the home. The registered people must urgently review the homes registration status to ensure that it only accommodates people with needs it is able that to meet and where it can keep residents safe. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans only contain basic instruction in relation to care that people require and need to reflect people more as individuals. People’s health care needs are met by the home. EVIDENCE: People who live at the home have a plan of care that instructs staff how their needs should be met. Care plans do identify peoples preferences such as the time they like to go to bed and get up in the morning, but generally care plans only contained basic information with comments such as “small appetite- eats only small meals but good appetite”. There is a need for care plans to be more “person centred” reflecting people as an individual. There were clear plans to ensure that residents ethnicity, cultural routines and religious choices were catered for and respected. Care records included risk assessments for moving and handling, falls, management of challenging behaviour, nutrition and formation of pressure sores. The home does not have any residents with pressure sores but there Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 12 are pressure reducing cushions and mattresses available to minimise the risk of pressure sores for vulnerable people. Residents are also weighed regularly and when there is any concern about their weight appropriate actions are undertaken. The home shows that they monitor the mental health of residents. The manager explained that a referral had been made for psychiatric support for a resident because of symptoms becoming obvious. There was good information on triggers to look for, for residents with diagnoses of depression that might indicate that a resident is becoming unwell. A number of residents receive care and review from the Community Psychiatric Nurses (CPN) or Psychiatrists and there was information about joint working with these professionals in the Care Programme Approach documents. Residents were also involved in making their plan. Residents’ files showed that residents overall health was reviewed to see if the care plans were still working. A number of residents refuse personal care. Records are available of care undertaken such as when they have a bath or shower and if they have refused care. Two residents seen had not had a shave, although this was not reflected in daily notes. The manager explained that one of the residents preferred one male member of staff to shave him, but this is not adequately documented in his care records. A senior member of staff showed the inspector the medication records. The management and safekeeping of medicines at the home is generally good. The home have medication in a monitored dosage system for the most part. There is a process of checks to ensure that the prescription and the medication received tallied. Residents’ photographs were with the Medication Administration Record (MAR) and this acts as another useful check. There were some gaps in the medication record for the administration of creams, staff do not always sign when medicines are not given (such as medicine for constipation and nutritional supplements) and were advised to record the appropriate code. The system could be improved by ensuring that the MAR has detail of allergies or states ‘none known’. The staff were observed assisting residents and this was done in a calm and consistent manner despite some challenging behaviour. One resident was insistent that the mattress was torn (although this was not the situation), another resident was verbally and racially abusive to staff and visitors yet staff were calm and appropriately managed these incidents. Residents wishes to remain in their rooms is respected by staff, as was a wish that they stayed in bed later in the morning. There has been an ongoing concern about access to the call bell from baths but the manager said that residents were not left alone in the bath. This may not be necessary for all residents and appropriate risk assessments should be in place to ensure that residents privacy, dignity and respect are maintained. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does not have rigid rules and routines and there are a range of activities available for its residents to meet their choice, preferences and capabilities. Food is tasty but as the menu is not always followed and choice is limited. EVIDENCE: Residents interests and their past hobbies are recorded in their care records and this is included within their plan of care. There is an Activities plan displayed on the wall in the dining room which includes activities such as bingo, magnetic darts, cards and skittles. During the inspection several games were organised and included the magnetic darts, cards and hoop a loop. It was good to hear that residents do go out and some are able to go out on their own. Residents spoken to thought visitors were welcome in the home. There was no evidence of restrictive practices in form of signs on the walls or in the visitors’ book to deter visits. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 14 Residents have a choice of how and where they spend their days. A number of residents spent time in their own rooms watching television, others sat in the lounge and joined in with any activities that are on offer. Residents were seen to have freedom of movement. The back door was alarmed to ensure that residents do not leave the building without a staff member knowing. The home has a four week menu with a choice of meals at lunchtime. Records of meals that residents had had identify that the menu is not always followed and there is not always an appropriate choice of meal available. Food choices given on the days preceding the inspection had been beef or corned beef and lamb chops with rice or lamb chops with potatoes. A resident spoken to said the food was ‘very good’ . The home has several West Indian residents and the home’s West Indian cook ensures that they have a Caribbean meal option most days- the day of the inspection it was chicken curry with rice. Tea is usually soup and sandwiches, although other hot snacks are also available. Residents also have a supper after 7.30pm which can be fruit, sandwiches or toast. The dining area has been considerably improved with new dining furniture and laminated flooring, tables were attractively laid and have new cruet sets available for each table. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. People are able to express their concerns but need appropriate information as to what they should do if their concerns are not addressed by the home. The diverse nature of residents’ needs and their behaviour may put some residents at risk. EVIDENCE: The home and the Commission have received no complaints about the home in the previous twelve months. Residents were observed to discuss their concerns with staff and the Manager, and appeared to be at ease doing so. The home does have a complaints procedure but it is not displayed in the home. There is a need to ensure that people who live at the home and visitors to the home are made aware who to make any concerns known to and the complaints procedure should be prominently displayed. The home does have a number of residents with challenging behaviour including violence and aggression which can be unpredictable. Incidents of verbal aggression seen during the inspection were calmly diffused by staff. It was advised that staff receive training in conditions that affect residents and should also have training in the management of violence and aggression. The home Manager has made two Adult Protection referrals and appropriate actions Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 16 have been undertaken to safeguard the homes residents. A number of staff have undertaken the adult protection training and there was evidence that staff performance is monitored. Staff receive copies of the General Social Care Council’s Code of Practice that states how staff are expected to behave. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21,24, 25 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Refurbishment is making some areas of the home more pleasant although other areas are dirty and shabby. EVIDENCE: The home has had some refurbishment including new carpets in communal areas, new laminate flooring in the dining room and new dining room furniture since the previous inspection making these rooms look pleasant and homely. There remains a need to refurbish bathrooms as staff only currently use the two assisted bathrooms on the ground floor. It was later identified that there was insufficient hot water in one of these bathrooms. Other bathrooms were found to be dirty including the new assisted shower which also had dead daddy long legs in it. One bath on the first floor by room 7 had the bath panel missing which was also highlighted at the previous inspection. The Proprietor Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 18 said that it had been repaired after the last inspection but had broken again and as it was now his plan to refurbish this bathroom next and it would be addressed then. The home record water temperatures although temperatures in some rooms could best be described as tepid, and in five rooms staff had recorded the temperature as “cold” although there was no record of either the bath or shower hot water temperatures which also needs to be undertaken. Bedrooms that have been refurbished are light and pleasant with modern furniture although the majority of remaining bedrooms look shabby and tired. Concern was highlighted at the previous inspection about missing light bulbs and although this had largely been addressed two over bed lights seen had no bulb in them and one light was left hanging off the wall. The floor in several areas was found to be uneven and represents a tripping hazard with areas that this was most noticeable being outside the kitchen and down from the Activities room where there appeared to be a small step under the new carpet. The home was generally free from offensive odour although there was a strong and unpleasant odour in two residents rooms. The home has a large garden with a large lawn and paved area. The garden furniture is shabby, with table tops that are lifting and could potentially injure residents, and dirty chairs. The Manager has said that she is looking at purchasing new garden furniture, which would be a great improvement. The previous inspection highlighted that the beams supporting the plastic roofing at the back of the home needed urgent attention and this has been undertaken. The paving slabs are also uneven and present a tripping hazard but the Proprietor has again identified that the slabs will be replaced. The were some areas that require improvement to safeguard residents from the risk of infection. Bathrooms and toilets require a thorough clean, improvement to the laundry such as a continuous laundry floor and walls that are easily cleanable. The Manager was also advised to ensure that contaminated laundry is placed into special laundry bags which are placed directly into the washing machine. There are also open joints in the kitchen floor where dirt and bacteria could accumulate which should be addressed. It was highlighted at the previous inspection that the clinical waste bin was unlocked with an incontinence pad left lying on the floor. The clinical waste bin at this inspection had just been emptied by the contractor and had been left unlocked, although there was no pads left lying outside the bin there were black bags of rubbish left out with other rubbish, including the remnants of the new carpet, which would attract vermin and this area must be clean and free from litter. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is sufficient staff to meet residents needs. Recruitment and selection procedures are robust and safeguard the service users. Staff training opportunities are good. EVIDENCE: The home staffing levels currently are three care staff throughout the daytime shifts from 8am to 10pm with management hours in addition and two care staff on duty at night. The home has a cook who works from 7am to 1.30 pm 6 days per week with a member of care staff taking on that role on the seventh day. There is also domestic staff seven days a week, although at the time of the inspection the domestic was on holiday. The home had met the target of 50 of staff having completed their NVQ2 and this ensures that a good number of staff are aware of how to care for the residents. Turnover of staff at the home is minimal and as a result the new Manager has not yet employed any new staff. Recruitment and selection procedures seen were found to be robust and safeguard residents with all required checks being undertaken before the member of staff commences employment. Staff also receive a full induction that is in line with the Skills for Care organisation guidelines. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a manager who is endeavouring to give effective leadership but this has been made difficult by the current, diverse and inappropriate mix of residents that the home. The home needs an effective quality assurance programme and to act more quickly when environmental issues were identified. EVIDENCE: The manager has been in post since January 2007 and has previously managed other care homes. She has recently completed her Registered Managers award. Staff said that the Manager is approachable with observations made during the inspection supporting this. There are also regular staff meetings that assist communication at the home. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 21 The Manager has been reviewing and updating the homes policies and procedures. The home does not have a quality assurance programme. A quality assurance programme would assist in the development of the home proactively identifying areas that require improvement and a direction for the home. There is also a need to solicit the views of residents, relatives, staff and other professionals about the home and improvements that could be made. The home does not act as appointee for service users but have in place good accounting practice to assist service users in keeping their personal allowance safe. Supervision has commenced with records seen demonstrating an effective formal supervision process although staff are not receiving formal supervision bi monthly as currently recommended. Health and Safety needs to be given a greater priority with a need to address concerns proactively rather than leaving maintenance until it represents a problem. A required check whether bacteria is present in the water has recently being undertaken and was satisfactory, although hot water in the home is insufficient for adequate bathing and washing. There are required records to demonstrate that checks on the fire alarm and emergency lightening system have been undertaken, all maintenance contracts seen were also up to date. Staff have generally received required training although records show that six staff had not received required training and the Manager is addressing this. It was also not evident that the cook had had food hygiene training although records identified that she had had intermediate infection control and the manager said that she would look into this further. There were no records to identify that staff have had first aid training. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 22 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x 1 x x x 1 1 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 3 2 x 1 Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 23 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 OP4 Regulation 14(2) Requirement The home must only accommodate people in categories of registration that the home is registered to accommodate and needs it can meet. The following matters must be dealt with as a priority: The bath panel in bathroom next to room 7 must be replaced to provide a corner that does not have a potential to cause skin tears. Timescale of the 22/9/06 partly met. The following must be rectified: - 31/08/07 The clinical waste skip must be locked and the area surrounding it kept clean and clear of clinical waste. Timescale of the 06/10/06 not met. The floor is levelled to safe guard 30/09/07 people who live at the home from the risk of accident. DS0000039328.V344685.R01.S.doc Version 5.2 Page 24 Timescale for action 30/09/07 2 OP19 13(4)© 23(2)(b) (c) 22/09/07 3 OP19 13(4)© 23(2)(b) (c) 4 OP19 13(4)(a0 Roseneath 5 6 OP19 OP21 23(2)(d) 23(2)(j) 7 OP21 23(b)(d) All parts of the home must be kept clean and be reasonably decorated. There must be provided at appropriate place in the premises sufficient numbers of lavatories, wash-basins, baths and showers fitted with a hot and cold water to meet peoples needs who live at the home. The home must inform the Commission the date by which the bathrooms on the first and second floor will be refurbished. Timescale of the 20/10/06 not met Residents must have access to emergency call points in their bedrooms and bathing and toilet facilities. Timescale of the 31/10/06 not met. This remained outstanding since 24/08/05 and 31/05/06. All lighting in the home must be in working order. Timescales of the 31/10/06 partly met. Previous time scale of 01/01/05 and 31/05/06 partly met. The home is kept free from unpleasant odour and a pleasant place to live. The odour in rooms 4 and 24 must be addressed. The proprietor must forward to CSCI his proposals to address the areas within the home that represent an increased risk of infection for people who live at the home. The home must employ enough cleaning staff hours to ensure a clean and fresh environment. Timescale of the 30/11/06 partly met The home must have a quality DS0000039328.V344685.R01.S.doc 30/09/07 31/10/07 30/08/07 8 OP22 13(4)(a) (b)(c) 31/10/07 9 OP25 23(2)© 31/08/07 10 OP26 16(2)(k) 31/08/07 11 OP26 13(3) 31/08/07 12 OP27 18(1)(a) 30/11/07 13. OP33 24 30/11/07 Page 25 Roseneath Version 5.2 14 OP38 13(4) assurance system that ensures residents’ views on the service can be listened to. Timescale of the 30/11/06 not met – Requirement outstanding since 31/07/06 The proprietor must make suitable arrangements for staff to receive first aid training to give assurance that staff would undertake appropriate actions in an emergency first aid situation at the home. 30/11/07 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 3 Refer to Standard OP7 OP9 OP9 Good Practice Recommendations Care plans should be “person centred” When it is necessary to hand write medication records, there should be two signatures to confirm the accuracy of the record. There should not be any gaps on the medication record. When medicines are not given staff should use the appropriate code to confirm the reason that the medicine was not given. Staff should sign for the administration of creams and lotions. Procedures should be reviewed to ensure that the home facilitates residents independence and promotes their privacy and dignity. 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 Snacks available for both people that need to increase weight and for those that are on a weight-reducing programme. Reflect the cultural preferences of the residents. DS0000039328.V344685.R01.S.doc Version 5.2 Page 26 4 5 OP10 OP15 Roseneath 6 7 8 9 10 11 12 OP16 OP18 OP19 OP25 OP25 OP26 OP26 The complaints procedure should be prominently displayed. Staff should receive training in conditions that affect residents and should also have training in the management of violence and aggression. The garden is made attractive place for residents including the addition of new garden furniture. Staff record hot water temperatures in bathrooms and shower rooms monthly. The “flow and return” hot water temperature is monitored and recorded at least monthly and is within required and safe temperatures. The laundry floor should be continuous to enable it to be easily cleanable. Algaenate bags should be used for infected and contaminated laundry. Roseneath DS0000039328.V344685.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V344685.R01.S.doc Version 5.2 Page 28 - 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!