Inspection on 05/02/08 for Roseneath

This inspection was carried out on 5th February 2008.

CSCI found this care home to be providing an Adequate service.

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 31/07/07

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 11:00 5th February 2008 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.V358351.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.V358351.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 Dementia (20), Old age, not falling within any registration, with number other category (30) of places Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The tregistered person may provide the following category of service only: Care Home Only (Code PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories Old age not falling within any othercategory (OP) 30 Dementia (DE) 20 The maximum number of service users to be accommodated is 30 2. Date of last inspection 31st July 2007 Brief Description of the Service: The home was formerly two large houses that have been converted into one large care home providing accommodation for up to 30 elderly people some of whom may have dementia. 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; with the majority equipped with hoists for those residents requiring assistance, the bathroom 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 pleasant garden with a patio area, shrubs and Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 5 lawns. Fees are included within the service user guide, but for up to date fees it is advised that the Home Manager is contacted. 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.V358351.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an inspection undertaken without any prior notice by one Inspector between 11.00 and 19.00. The inspection included a review of information supplied by the Home Manager called “`An annual Assurance Assessment” which provided information about the establishment, policies and procedures at the home, information about the homes residents and its staff. Before the inspection seven residents completed a survey form known as “have your say about…” telling us about their experiences of life at the home. Four staff also returned a “Have your say” survey telling about their experience of working at the home. During the inspection the we followed the experiences of living at the home for three residents, including looking at their care records, conversations with them, viewing their rooms and if possible talking to their relatives whenever possible. This process is known as case tracking. We were able to meet with and talk with other residents and staff. Who told us in their opinion of what it is like to live in the home. A tour of the residents’ rooms and communal and service areas was completed and records about safety of equipment and the building were checked. Twelve of the previous fourteen requirements have been addressed, or removed as they are no longer applicable. Four new requirements were made as a result of this inspection. The outstanding requirements were discussed with the Proprietor during the inspection and confirmed that they would be addressed within two weeks, confirmation has been received that work has commenced to level the floor outside the kitchen and replace the floor covering and completely replace the staff call system within 168 Hamstead Road. There were also twelve good practice recommendations. What the service does well: The home has a stable group of care staff with the majority holding a care qualification. Staff are knowledgeable and are able to diffuse challenging incidents and speak to residents in a caring but clear, calm and professional manner. A relative says its is: Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 7 “ a lovely home, the staff are very friendly and we feel that our uncle is very happy” Food at the home is generally all home cooked and residents generally say that they like it although there remains an issue about the lack of choice. The home has a plan of activities and it was evident that activities take part throughout the day and residents are also to go out with support regularly. The staff and the manager are clear about practices that may be abusive. Incidents that may cause concern are reported to the Commission without delay and are appropriately dealt with by the manager. What has improved since the last inspection? What they could do better: Record keeping needs to be improved to evidence all positive improvements at the home. Whilst staff have received training since the last inspection records of this training was not available. The recruitment and selection of staff needs to be more robust. A new criminal records check must be gained before new staff commence employment at the home. References and employment history must be authenticated to provide confidence that all possible measures are in place to ensure that people who are unsuitable to work with vulnerable adults do not. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 8 Care planning needs to be more comprehensive and reflect all residents needs, choices and capabilities, to give greater assurance that staff will be made aware of all residents needs and have instructions how to meet them. The use of advocacy services needs to be explored to give greater opportunity for staff to enable residents to voice their feeling and choices. Staff must have greater awareness of their responsibilities under the Mental Capacity Act to give greater assurances that residents capacity to consent has been assessed and that when decisions have been made on their behalf they are in their best interests. There remains 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. 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.V358351.R01.S.doc Version 5.2 Page 9 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.V358351.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3, 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the home and its residents is available although it needs to be updated to ensure that accurate and complete information is available for people to make an informed choice that the home is suitable for their needs. EVIDENCE: The home has both a statement of purpose and service user guide. The manager needs to update both documents to reflect the recent changes in registration enabling the home to care for people with dementia and therefore provide people with all required information about the home. Residents have terms and conditions of residency, with copies generally available within their care records. Contracts seen were complete although one slight omission was addressed before the inspection was completed by the Home Manager. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 11 People have an assessment of their needs before coming to live at the home, which is undertaken by the home manager. Information which is obtained from the assessment of their needs, is then incorporated into their plan of care. However no assessment of need was available for the most recently admitted resident. The home manager writes to prospective residents to confirm that following their assessment of need the home is able to meet their needs. It was advised that terms and conditions of residency are also sent out at this time and people are asked to sign one copy and return it when they come to the home. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s healthcare and personal needs are generally met but the sometimes poor record keeping systems may mean that some peoples needs may not be recognised and therefore not fully addressed. Medications are safely stored and administered although slight improvement may give additional confidence that people are safeguarded from possible error. EVIDENCE: Residents do have a plan of care but care plans need developing to include additional information such as food likes and dislikes and residents’ capabilities. A resident whose care records were checked, staff identified that they had concerns about smoking and that he was a risk to himself and other residents. This persons care plan did not even identify that he smoked and that there were some of the concerns about his smoking, and then did include any instructions for either the resident or staff. A risk assessment was available but again this was only basic and did not reflect the risks, such as Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 13 where his room was allocated, that he dropped lit cigarettes on himself and furnishings and despite “house rules” of no smoking in bedrooms he did so. Care records of residents with previous alcohol dependency were also seen and again this was not included in their plan of care. Another resident had communication problems but this was not clear in his plan of care and ways that staff may be able to communicate and understand this resident more effectively. Care plans specified that some residents “needed assistance or support” with personal care and dressing but did not specify what they could do for themselves and what “assistance” they required. There is a ”personal hygiene” record but the one resident whose care records were looked at only had a “strip wash” for the entire of January and the February until the day of the inspection, although there was no record that staff had tried to encourage him to bathe or shower. There were some risk assessments for moving and handling, falls, management of challenging behaviour, nutrition and formation of pressure sores but again risk assessments were basic and again inconsistently completed. Residents are also weighed regularly and when there is any concern about their weight appropriate actions are undertaken one family included a compliment how staff had addressed concerns about their residents weight loss. People who live at the home are regularly seen and have access to other health professionals such as GPs, District Nurses, Community Psychiatric Nurses, Psychiatrists, Opticians, Chiropodists, dentists and records were available to evidence this. The management and safekeeping of medicines at the home is generally good. The home receive medication in a monitored dosage system for the most part. There were some gaps in the medication record for the administration of creams. The system could be improved by ensuring that handwritten entries are signed for by two members of staff to confirm the accuracy of the entrythis was also highlighted as a cause for concern at the previous inspection but has not been addressed. Some residents have challenging behaviour and observations made at this and previous inspections have been that staff assist residents in a calm and consistent manner. A number of residents choose to remain in their room during the day and this is respected by staff. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a daily life that is generally suitable for residents, their needs and choices although further improvements can be made to ensure that adequate choice is always available. EVIDENCE: Residents interests and their past hobbies are recorded in their care records and this is sometimes but not always 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. Residents spoken to also confirmed that they go out to the post office and shops. Visitors are 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. One comment card that had been completed by a visitor said: “lovely welcome extended over several visits with an area to sit and chat with tea provided just if we had visited my aunt in her own home in past times.” Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 15 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 throughout the home as they wished, although key pads have been applied to the kitchen and laundry doors for residents safety. A number of the CSCI resident surveys had been completed by staff assisting residents. The use of advocacy services was discussed to ensure that residents’ voices are heard and there is assurance that all issues are highlighted, which may not be the situation if staff are included in the completion of surveys. The Mental Capacity Act 2005 was also discussed with the manager as it was evident that staff generally have a limited understanding of the Act and their roles and responsibilities within it. It was advised that staff have training on the Mental Capacity Act. The home has a pleasant dining area with new dining furniture and laminated floor, tables were attractively laid and have new cruet sets available for each table. It was nice to see that mealtimes were made “an occasion” and the majority of residents chose to come into the dining room for their meals. The home has a four week menu with a choice of meals at lunchtime. Records seen demonstrated that the menu is not always followed and a choice is frequently not available of either main meal or pudding. On the day of the inspection there was curried chicken with creamed potatoes and sprouts with mixed fruit crumble and custard. One resident told said “the curry at lunch time was really nice”. Another resident said he like eggs and is able to have them whenever he likes. The home has several West Indian residents and the home’s West Indian cook ensures that they have a Caribbean meal option most days. 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. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 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 highlight concerns although there is insufficient information available to give confidence that staff will know actions to take when abuse is alleged and to safeguard people who live at the home. EVIDENCE: The Manager has updated the complaints procedure and it is now displayed both in the lounge and dining room. There have been no complaints about the home either received by the Commission for Social Care Inspection or directed directly to the home. It is also positive that the Home also encourages compliments about the home to encourage good practice, two letters of “compliment” were seen during the inspection. Observations made both at this and previous inspections show that there is a good and open relationship with the manager and any concerns are immediately addressed. The home does have a number of residents with challenging behaviour including violence and aggression. It was advised at the previous inspection that staff have training in the management of violence and aggression which has been undertaken although no records were available at the time of the inspection. The Manager also consistently demonstrated that she is an excellent role model dealing with incidents of aggression calmly and professionally. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 17 There has been one recent Adult Protection investigation at the home that is still ongoing. The Manager has ensured that appropriate actions are undertaken to protect the residents involved. The home does not have its own safeguarding policy or a copy of Birmingham City Council Safeguarding policy, which the homes own policy should reference. The manager was advised there is a need to ensure that both policies are available to give staff appropriate information in the absence of the Home Manager. Some staff have had adult protection training although records of this training were not available in the staff files looked at during the inspection. There is a need to ensure that all staff have Adult Protection training and are made aware of the relevant policies to ensure that residents are protected from harm and that staff are aware of the required actions that they should undertake. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 18 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): 19, 20, 22 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is homely, clean and warm, planned improvements will also make the home safe and more suitable for its residents. EVIDENCE: The home was found to be warm, clean and homely. The refurbishment of the home is ongoing with two bathrooms completely replaced with new bathroom fitments, tiling and the installation of a new bath hoist. Both the Manager and the Proprietor gave their assurances that the refurbishment will continue: “We must keep updating the décor of the home and make sure that it is clean and safe and comfortable for service users”. The floor in the corridor outside the kitchen and Activities room is uneven and represents a tripping hazard, this was highlighted at the previous inspection. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 19 Confirmation has been received since the inspection that the floor will be levelled the existing carpet removed and new flooring laid and that this work will commence on the 15th February 2008. The home has a large and mature garden with a large lawn and paved area. Improvements made to the garden since the previous inspection has included: paving stones have been taken up and re-laid so that they are even, new fencing and new garden furniture is also now available. The manager said they would be buying a barbecue which they will be able to use when the weather improves. The Proprietor has addressed previous problems with the hot water ensuring that hot water is available throughout the home for washing and bathing. The home has a staff call system. Problems have been highlighted since 2005 that the call points from either baths and toilets could not be accessed in the part of the home that was previously 165 Hamstead Road. A quotation has been requested to replace the entire staff call for 165 and confirmation has been received since the inspection that this will be undertaken before the end of February 2008 to replace the entire staff call system. There has been a considerable improvement in the cleanliness of the home with the appointment of a new cleaner and the availability of cleaning staff seven days a week. The was remarked on by one relative who returned a survey to the Commission for Social Care Inspection: “The standard of hygiene appears high.” A resident also said “it’s a very clean home” Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 20 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): 27, 28,29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is sufficient staff with appropriate skills to meet the needs of people who live at the home, however the lack of required records fail to give assurance that safe recruitment is undertaken and that staff have all required training. 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. Turnover of staff at the home is minimal with the majority of staff spoken to having worked at the home for several years. The home manager said that all but one member of staff has completed a care qualification (National Vocational level 2 qualification). Records of staff qualifications were not available in all those staff files that were seen during the inspection. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 21 Staff turnover is minimal at the home and there has been just one new member of staff since the previous inspection. This employee’s staff file identified several shortfalls these included: The criminal record check on file was for a previous employment, with no new criminal records check available for employment at Roseneath and despite her employment since September. An application form was available but the employment history was incomplete and did not include all places that the person had been employed. References were available from this the most recent employer as required although this employment was not included within the application form. There was also no job description or contract of employment included within the staff file. There was also no record of any induction, although previously staff at the home have undertaken induction that meets the Skills for Care guidelines. The Manager said that all but one member of staff has a care qualification (a minimum of National Vocational level 2) although no documentary evidence of this was available within those staff files seen. It was also noticed that staff records had not been updated to reflect recent training that staff had received including dementia care since the previous inspection. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager provides a good role model in providing care and support to residents although record keeping in generally not up to date or complete to support management processes that have been undertaken. EVIDENCE: Gill Goode has been the Home Manager since January 2007 and has previously managed other care homes. She has completed her Registered Managers award and also undertakes regular training updates. 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. A relative said Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 23 “Gill talks of her plans for the home enthusiastically and we have the feeling she really enjoys all the people that she is working with. She is backed up by a pleasant staff team who were always chatty and responsive.” It is evident that the manager provides good leadership in the support of residents and has good relationships with both residents and staff. A major weakness at the home is record keeping and that the frequently poor record keeping does not provide required evidence of many of the good practices that take place at Roseneath. The home has no quality assurance programme which if available would assist in identifying areas that require development at 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. An Annual Quality Assurance Assessment (AQAA) was completed and sent to the Commission for Social Care Inspection by the Home Manager before the previous inspection. The AQAA needs to be more detailed and may assist the Home Manager in developing a Quality assurance programme. The home does keep small amounts of money on behalf of some residents. There is a record of all transactions and receipts are usually obtained. The records were not up to date with recent receipts not available within the residents’ records and so could not be checked for accuracy and authenticity. The Manager must ensure that all residents’ money can be accounted for and records are always kept up to date. Staff receive supervision with records seen demonstrating an effective formal supervision process. Supervision is not undertaken as frequently as required with a gap of several months in between supervision sessions. Staff supervision can give a confidence that staff are working appropriately and their knowledge is appropriate and up to date. The previous inspection identified areas that were potentially putting residents at risk the majority such as hot water checks have been addressed whilst others such as the levelling of the floor and a new call system are in place. Maintenance checks seen were all up to date. Staff have mandatory training in areas such as moving and handing, fire, food hygiene and protection of vulnerable adults although records seen highlighted that training is not up to date. It was highlighted at the previous inspection that the cook had not got required intermediate food hygiene qualification and this is still outstanding. The Manager confirmed that staff had had first aid training but certificates were not available at the time of the inspection. Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 24 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 2 3 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 3 x 2 x x x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x 2 2 x 2 Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Timescale for action 05/03/08 2 OP7 15 3. OP19 13(4)(a) People should have an assessment of their needs, choices and capabilities before they come to live at the home to give assurance that the home will be suitable to meet their needs. People who live at the home 05/03/08 must have a comprehensive plan of their care that identifies all their needs, choices and capabilities to ensure that staff are aware of their needs and actions that are` required to address them. The floor is levelled to safe guard 31/03/08 people who live at the home from the risk of accident. 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. Recruitment and selection procedures must be robust to DS0000039328.V358351.R01.S.doc 4. OP22 13(4)(a) (b)(c) 31/03/08 5 OP29 19 05/03/08 Roseneath Version 5.2 Page 26 6 OP35 13(6) ensure that residents are protected from people who are unsuitable to work with vulnerable people. There is a comprehensive record of people money when it retained for safekeeping with evidence of all transactions, to give confidence that residents are protected from financial abuse. 05/03/08 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 OP1 OP7 OP9 Good Practice Recommendations The statement of purpose and service user guide are updated to reflect recent changes to the homes registration. 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. Staff should have training to highlight their and the homes responsibilities under the Mental Capacity Act. The use of advocacy services within the home should be explored. Meals provided must reflect what is offered on the menu and reflect a choice for residents, have regard to their likes, culture and nutritional needs The menu must show: DS0000039328.V358351.R01.S.doc Version 5.2 Page 27 4. OP9 5 6 7. OP14 OP14 OP15 Roseneath 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. 8 9 10 8. OP18 OP18 OP18 OP25 The home has an “Safeguarding policy” The home obtains a copy of Birmingham City Council Safeguarding policy. Staff all receive training in the awareness of what constitutes abuse and actions that are required when abuse is alleged. 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. The home should have a quality assurance system that ensures residents’ views on the service can be listened to. Staff should receive first aid training to give assurance that staff would undertake appropriate actions in an emergency first aid situation at the home and there should be a record of their training. There should be a comprehensive record of all training that has been undertaken 9. 10 OP26 OP33 11 OP38 12 OP38 Roseneath DS0000039328.V358351.R01.S.doc Version 5.2 Page 28 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.V358351.R01.S.doc Version 5.2 Page 29 - 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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