Inspection on 27/07/06 for Roseview Home

This inspection was carried out on 27th July 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roseview Home 12/07/07

Roseview Home 09/01/06

Roseview Home 13/06/05

Roseview Home 11/11/04

Roseview Home 12/07/04

Roseview Home 23/02/04

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

CARE HOME ADULTS 18-65 Roseview Home 26 Bounds Green Road London N11 2QH Lead Inspector Karen Malcolm Key Unannounced Inspection 27th July 2006 10:35 Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 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 Roseview Home DS0000010752.V298129.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 Adults 18-65. 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. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roseview Home Address 26 Bounds Green Road London N11 2QH 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) 020 8368 9195 020 8361 5114 Mrs Agatha Annin-Adjei Mrs Angelina Otoo Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: Roseview is a care home registered to provide accommodation and personal care for a maximum of six younger adults with mental disorders. The Homes aims and objectives state that the home: • Encourages service users to take part in decision-making processes. • Ensures service users have privacy and dignity. Maintains service users personal identity and choice. Involves service users in policy reviews. • Ensures service users and staff work together to achieve these goals. The home is a semi - detached, two-storey house that was opened in May 2001. It has six single bedrooms. None of the bedrooms have en-suite facilities. On the ground floor, there are two bedrooms, an office, a kitchen, lounge/diner, a smoking area, a shower room with a toilet and a separate toilet. On the first floor, there are four bedrooms, a phone room and a bathroom with a toilet. There is a small front garden and an attractive larger back garden, which is partly paved and accessible to service user. The home is situated along the busy Bounds Green Road and close to a large selection of restaurants, shops and community facilities. Wood Green Shopping Centre is about a mile away. Bounds Green underground station is within a short walking distance. At the time of the inspection the home was fully occupied with six service users living at Roseview. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. “The cost of placements is £475 - £500 Following “Inspecting for better lives” the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Additional cost is for the chiropodist. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed approximately over six hours. In the home were two male care staff, four service users and one service user was at the day centre. The registered manager and the care co-ordinator arrived about forty-five minutes after the inspection started. Both assisted the inspector throughout the inspection. The inspector was able to speak to four service users independently and together. One service user gave the inspector a guided tour of their bedroom. The service user was very positive about the home and the care they receive. However, they raised some questions around equalities and diversity, which have been addressed in the main body of this report. The manager and care coordinator were very open and helpful throughout the inspection. At the previous inspection one Immediate Requirement was issued regarding the home’s staffing levels. Prior to this inspection the registered provider submitted an action plan to the Commission addressing the Immediate Requirements made. At this inspection this was checked and it was evident that compliance had been achieved. Outside of the inspection a meeting was held with regards to the requirements made in the previous inspection report. Attendees of the meeting were the registered manager, care co-ordinator, the regulation manager and the inspector. The outcome of the meeting was to ensure that staffing levels in the home are constantly reviewed and maintained. This inspection involved sampling care plans, policies and procedures, other records, a tour of the building and observing the interaction between staff and service users, this was found to be positive. As the inspector was leaving the home, service users were participating in an art lesson supported by the carers on duty. The interaction observed by the inspector was deemed good. One service user showed the inspector their artwork, which was impressive. Overall the inspector’s impression was that the home remains well managed and some progress has been made to meet a number of areas of improvement from the last inspection. What the service does well: All the service users have lived at the home for a number of years. All the service users have their own bedrooms, but share the communal areas. The garden is large with a patio and grassed area, which is beautifully maintained. The home is a family business and all the family members are involved in the running of the home. The care co-ordinator ensures that the home is run according to the Care Homes Regulations 2001 and National Minimum Standards for Adult 18-65 (NMS). The majority of service users are Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 6 independent and are supported appropriately by the staff when needed. The service users spoken to stated that they like living in the home. What has improved since the last inspection? What they could do better: This inspection has identified fifteen areas of improvement and three recommendations. Two areas for improvement have been restated from the previous report both were partially met at the time of this inspection. The registered person is required to submit an action plan to the Commission for Social Care Inspection (CSCI), which describes how they will address these matters. The summary identified in this report is that the registered person is to include in the home’s environmental risk assessment an assessment of the exposed pipes in the laundry area that cannot be boxed in. The home’s policies and procedures especially the medication is to be reviewed and amended accordingly. Guidelines for PRN medication need to be in place and one specific service user’s medication daily dosage needs to be recorded separately. One bedroom is in need of redecoration and the hallway and lounge carpet are in need of a thorough clean. It is reminded that a record of all visitors to the home is recorded in the home’s visitor’s book. On each shift there must be at least one female carer rota’d on and all Health and Safety certificates must be kept in the home. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 7 Unmet requirements impact upon the health and safety of service users. Failure to comply with the timescales will lead to the Commission for social Care Inspection considering enforcement action to secure compliance. The three recommendations stated in the table at the back of the report are deemed as good practice. 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. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Service users assessed care needs have been addressed appropriately by the home. EVIDENCE: All six-service users have been at the home since it opened in 2001. Service user plans sampled indicated that community care assessments had been completed by placing authorities prior to each individual’s placement in the home. At the previous inspection one service user was in hospital for a period of time to review the individual care needs. It was evident at this inspection that this has now been reviewed and the appropriate care and support needs are now in place for that specific individual. Admission is not made to the home until a full needs assessment has been undertaken. The assessment is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. Where the assessment has been undertaken through care management arrangements, the service insists on receiving a summary of the assessment and a copy of the care plan. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Service users care plans are in place and have a detailed account of individual’s assessed and changing needs. EVIDENCE: All service users have care plans. The plans were generally comprehensive and addressed the assessed needs of service users. Service users confirmed that they had been consulted regarding their plans. Service users are aware of their health needs and at times have flagged this up with the registered manager. Two service users informed the inspectors of their achievements regarding their health care since the last inspection. Evidence of updating information and changing actions appears on care plans. The majority of service users confirm their involvement in developing the plan and most receive feedback on decisions made during reviews. Risk assessments are in place, but can be improved. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 11 There are policies and procedures in place to ensure that service users are informed of their rights to confidentiality, and understand when staff may share information to ensure individuals are safeguarded. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Service users are able to participate in appropriate activities within the community independently and sometimes with support. Service users relationships are positive and good. The service users are happy with the meals provided by the home. EVIDENCE: Individuals are treated with respect, privacy and dignity in the home. The records indicate that service users lead quite independent lifestyles. They have keys to the front door and their bedrooms. There are few restrictions imposed, and a service user stated that they were always treated in a dignified manner and staff respected their privacy. The inspector spoke to several service users with regards to a number of issues, food, activities and whether or not they like living at the home. Seeing that the inspector has been inspecting this service for a number of times, the inspector has become familiar with the surrounding and the service users. The feedback for each service user spoken to were positive and interesting with regards to their Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 13 personalities, likes and dislikes. Service users were honest, open and shared their highs and lows of living in the home. One service user invited the inspector to their birthday party, which was happening in November. At the beginning of the inspection the inspector observed a service user becoming upset and anxious about a task they were asked to complete. It was evident from the discussion that the service user was unhappy about the situation. The inspector intervened and asked the service user what they wanted to do and the service user gave their choice. However, the manager and the care co-ordinator stated that they were unhappy that the inspector had intervened and the manager felt undermined by the inspector’s intervention. The situation was discussed at length. The outcome of the discussion was that the decision made to intervene was to ensure that the service user was happy. Service users are given the opportunity to take part in a variety of activities both within the home and the local community. One service user stated ‘that they used to go to a day centre and activities included strawberry picking and dancing. However, the centre closed down and the service user stated that they have not gotten the energy anymore to participate in activities such as dancing as their feet are warn out’. The home has in the past received a number of complaints regarding begging in the community specific to one service. This has been addressed with the individual and their social worker. The manager stated that this has now been addressed with local traders however, the service user still continues this practice and local traders have got used to it. The manager stated that recently an anonymous complaint was received and the care co-ordinator is addressing this. Where appropriate service users are involved in the domestic routines of the home, they take responsibility of keeping their bedroom neat and tidy. At breakfast all service users make their own choices regarding what they want to eat. Meals are balanced and nutritional. Service users shared their likes and dislikes about meals provided. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Service users healthcare and personal support needs are addressed by the home. The medication is well managed therefore promoting good health. However, medication procedures and some practices are in need of reviewing to ensure current practices are in place. EVIDENCE: At the previous inspection a requirement was made regarding the manager making an appointment with the GP or the Dietician with regards to the current blood sugar levels for a specific service user who is diabetic. It was evident at this inspection that an appointment with the diabetic nurse was made and information pertaining to this was on file. The home has ceased taking blood sugar tests for the specific service user and the nurse now completes this. However, the manager stated that staff are having a constant battle with the service user regarding healthy eating, maintaining their health and generally looking after themselves. Evidence of the staffs intervention and advice was not recorded on the care plan, although the manager gave the inspector a clear account of what were the difficulties. It was advised that the manager must record any advice, or intervention made by staff to ensure that the specific service user is receiving the proper care and advice that they need. The inspector spoke to the specific service user. From the discussion it was Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 15 evident that the specific service user is aware of their health problems, however, they stated that they can’t help themselves and have tried. At the previous inspection another service users health needs was discussed regarding chiropody treatment and their general health regarding smoking. It was evident that the service user has had a chiropody appointment and that the manager stated that staff now accompany the service user to their appointment and record exactly what treatment was given. Regarding the service users general health this has also been a battle, but the service user is more acceptable to the new smoking programme being introduced. However, at times the individual can also become difficult. The manager has put strategies in place for staff to support the individual when this occurs. Staff spoken to understand the key principles of giving personal support and are responsive to the varied and individual requirements of the service users. It is recognised that the delivery of personal care is highly individual. When ever possible, service users are able to have a choice about who delivers their personal care. Where possible, service users are supported and helped to be independent and responsible for their own personal hygiene and personal care. The home has a good record of compliance with the administration and safekeeping of medication. Records showed that all staff have undertaken medication training. However, there are four areas, which were identified at the inspection relating to medication, which the manager must address: • Correction fluid ‘tippex’ must not be used on the any of the Medication Administration Records (MAR), • Guidelines for any service user on prescribed PRN medication must be kept on file • The medication policy and procedure must be updated to reflect any current relevant legislation, as the current policy in place is dated 1999. • The specific service user who is prescribed Quetiapine 400mg, 600mg evening and 200mg in the afternoon must be recorded separately on the MAR sheet rather than together During the inspection one of the service user’s Clinical Psychiatry Nurse (CPN) visited. The CPN also spoke to the inspector. The CPN spoke positively about the home and the support the home provides especially with regards to an individual’s complex and special needs. Service users sexuality was discussed with the manager. The manager stated that some service users are very open and tend to share this with the staff in a joking manner. However it was not clear whether staff were able to support individuals appropriately in this area. It was advised that the home should obtain further advice and guidance through an advocate or arrange additional training for staff and service users to attend. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Service users are confident that all care staff have undertaken the adult protection training, therefore service users are protected from any form of abuse since care staff would be able to act appropriately to protect them. EVIDENCE: The home has a complaints procedure in place. However, as discussed with the manager and the care co-ordinator the complaints policy needs amended to be in line with the local authority policies and procedures. The policy must be also accessible for service users, a copy placed on the notice board and written in language for all the service users to read or access at their own leisure. Training of staff in the area of protection is regularly arranged by the home. The home has an open culture, which enables service users to express their views and concerns in a safe and non-blame environment. Staff spoken to were aware of what to do in the event of reporting an incident or an abuse. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The home is reasonably clean and comfortably maintained ensuring service users have a secure place to live. However, a number of minor maintenance areas of repairs or replacements are needed. Therefore the service users’ home could be deemed unsafe with areas of a potential risk hazard if not addressed to a good standard. EVIDENCE: The home is a semi-detached, two-storey house. It has six single bedrooms. None of the bedrooms have en-suite facilities. On the ground floor, there are two bedrooms, an office, a kitchen, lounge/diner, a smoking area, a shower room with a toilet and a separate toilet. On the first floor, there are four bedrooms, a phone room and a bathroom with a toilet. There is a small front garden and an attractive larger back garden, which is partly paved and accessible to service users. The service users spoken to were happy with the enviroment they live in. The garden area was used constantly by service users and as the weather was very hot on the day of the inspection the inspector was in the garden with the service users. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 18 The carpet in the lounge/dining area has been replaced, which was a requirement from the previous inspection report. However, the carpet choosen now is light in colour and it was evident that each spillage stain or dirty foot marks showed up clearly on the carpet. The manager stated that this may have been the wrong colour to choose, because now the carpet is now in need cleaning. All the bedrooms were examined. Although service users maintain their bedrooms themselves, it was evident that some were in need of a through cleaning too for. One service user who smokes constantly in their bedroom, evidence of cigarette burns were found on the rug. It was discussed that as part of the home’s fire risk plan this rug will need replacing frequently. One service user’s bedroom was in need of redecorating. At the time of the inspection the washing line was broken and this was being repaired by the handy person. It was reminded that all person/s entering the home, must sign the visitors book. The laundry area was examined, this was found in good order. At the previous inspection it was required that the exposed pipes in the laundry area are boxed in ensuring access can be made if needed. The manager explained that if they boxed the pipes in this would restrict the access to the small room. It was advised that the home’s envromental risk assessment must be updated to include what the risks are and how this can be minimzed. One bathroom examined was presentable however there was no towel for service users to use. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Staffing levels in the home have improved, however, the rota does not always fit around the gender issue of individual service users needs, therefore this needs reviewing by the manager. The home has a good recruitment policy and practice and service users benefit from a trained and well supported staff team. EVIDENCE: The staffing levels are eight carers, five of which are female. The rota shown to the inspector reflected the staff on shift on the day of the inspection. At the previous inspection an Immediate Requirement was issued relating to staffing levels. Prior to this inspection an action plan addressing the Immediate Requirement was submitted to the Commission. On the day of the inspection the inspector was greeted by two care staff, both of which were male. At a previous inspection dated 11th November 2004, it was recommended that the registered person consider employing a full time male member of staff to ensure that the gender balance within the staff team and service users were being supported appropriately. As at the time there was one specific service user who made offensive or suggestive remarks to female staff and service users. At this inspection the staffing was discussed and the rota was examined. The manager stated that this happens occasionally due to sickness, annual or training. The rota examined reflected that during the Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 20 current week only two male carers were on shift and that was the day of the inspection. The manager also stated that the female service users don’t need support with their personal care. It was advised that at no time should there be two male carers working together, as the female service users may on occasion need support and this would be inappropriately handled if this support is by male carers. Service users are generally satisfied that the care they receive meets their needs. Two staffing records were examined. The home has a recruitment procedure that meets the regulations and the National Minimum Standards. The procedure is followed in practice and there is accurate recording at all stages of the process. Each new staff member has an induction schedule list, which is listed from A – Z. One staff member spoken to stated that they had a good induction programme and they learnt a lot about individual’s needs. The training for the two staff examined were, first aid, Protection of Vulnerable Adults and dementia. The inspector asked the manager why staff had not had mental health training however, staff have undertaken dementia training. The manager stated that staff work in the other homes within the organisation and these homes are for older people. It was advised that staff must undertake mental health training and all the statutory training as stated in NMS 42. A part of the inspection process was for the inspector to observe handover with staff. Staff were very detailed about individual daily routines and personal care support. Staff are very knowledgeable about individual needs in the home. All service users have key workers. A key-working list was displayed on the office notice board. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The manager has a good ethos and management approach to running the home. Service users views are sought by the home and reviewed regularly. EVIDENCE: It was observed that the service users got on well with the manager and they seem to be more willing to ask her for advice than the staff on duty. Staff were also asked about the manager’s leadership and style. One staff member stated that the manager is flexible and very pleasant and they had no problems with her. Quality assurance is sought regularly by the home, however, from the discussion it was evident that the same questionnaire is used each year. It was advised that the home should target the question areas to review such as activities. The home produces a newsletter for the service users called ‘Bound Green Newsletter’ the copy shown and read by the inspector showed that a few of the Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 22 service users contributed to the information provided. There was a piece on what one service user thought of the home, a joke, poem and a section on advice. It was not evident from the newsletter read when this was produced and how often it was published and whether it was sent to relatives and other stakeholders. The inspector commended the document. The home’s policies and procedures were in place. However, the policies have not been reviewed for a number of years. The manager and care co-ordinator stated they had been reviewed however no dates were on the document stating this. It was also advised that each policy must have an aim and objective, (guidelines to assist the person reading it and what they should do). Within the home there is evidence of a reasonable awareness and understanding of equalities and diversity. The issue of inappropriateness with regards to sexism has been addressed by the home. However, the home policy regarding equalities and diversity needs to be updated to be in line with the current legislation and the issues that may pertain to the home. Health and safety certificates were requested. It was evident that the gas, Portable Appliance Testing (PAT), insurance and Electrical installation certificates were kept at the Head Office (The Limes). A copy of the appointment for the gas engineer was submitted to the Commission prior to this report being completed, however, no certificate was submitted. It was advised that all health and safety certificate pertaining to the home must be kept in the home. If there is a joint certificate for all homes such as the insurance certificate an up to date copy of the certificate is to be given to each home. it was also evident that the home does not have an appropriate facilities for communication by facsimile transmission. During the tour of the building it was evident that fire doors were found to be closed at all times. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 2 X 2 X Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13(4) & 23(2)(d) Requirement The registered person must clean the carpet in the lounge/dining area and either replace or thoroughly clean the stair carpet. Previous timescale of 13/03/06 partially met The registered person must include in the home’s environmental risk assessment a thorough risk assessment of the exposed pipes in the laundry. Previous timescale of 28/02/06 partially met The registered person must keep an accurate record of any health advice and treatment for the specific service user who is diabetic. The registered person must update the medication policy to be in line with current relevant legislations. The registered person must ensure that there are clear and precise guidelines in place for care staff to follow when administering PRN medication to service users. DS0000010752.V298129.R01.S.doc Timescale for action 30/09/06 2. YA30 13(4) 28/09/06 3. YA18 17 30/09/06 4. YA20 13(2) 30/10/06 5. YA20 13(2) 20/10/06 Roseview Home Version 5.2 Page 25 6. YA20 13(2) The registered person must ensure that the specific service user on Quetiapine medication is recorded separately for each daily dosage. The registered person must ensure that correction fluid ‘tippex’ is not used on MAR sheets. The registered person must ensure that the specific service user’s bedroom is redecorated. The registered person must ensure that there is towel for service users to dry their hands on in the bathroom. The registered person must keep a record of all visitors to the home. The registered person must ensure that on each shift at least one female worker is rota’d, to ensure that the female service users are supported appropriately. The registered person must ensure that care staff working in the home complete as part of their induction mental health awareness training. The registered person must ensure that all the home’s policies and procedures are reviewed and amended accordingly to be in line with current relevant legislation. The registered person must obtain the views of stakeholders including care managers with regards to the quality of care the home provides for service users they place. Evidence of this must be made public once collected. The registered person must ensure all Health and Safety certificates required for DS0000010752.V298129.R01.S.doc 20/09/06 7. 8. YA26 YA27 23(2)(d) 13(4) 30/10/06 20/09/06 9. 10. YA24 YA33 17(2) Sch 4.17 18 20/09/06 20/09/06 11. YA35 18 30/10/06 12. YA40 17 30/10/06 13. YA39 24 30/10/06 14. YA42 13(4) 20/09/06 Roseview Home Version 5.2 Page 26 inspection are kept in the home. 15. YA42 16(1)(ii) The registered person must have appropriate facilities for communication by facsimile transmission (fax machine). 20/09/06 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 YA15 YA39 YA40 Good Practice Recommendations The registered person should seek further advice and support with regards to supporting service user around their sexuality. The registered person should ensure that The Bound Green Newsletter is dated. It is recommended that all policies are dated, and signed and dated on review to evidence that a review has taken place at least annually. Roseview Home DS0000010752.V298129.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Roseview Home DS0000010752.V298129.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. 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