Inspection on 09/01/06 for Roseview Home

This inspection was carried out on 9th January 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 21 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 27/07/06

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 M Malcolm Unannounced Inspection 08:50 9 January 2006 th Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 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.V265384.R01.S.doc Version 5.0 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.V265384.R01.S.doc Version 5.0 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.V265384.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2005 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 Home’s 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 users. 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. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately four hours arriving at the home at 8.50 am. Margaret Flaws accompanied the lead inspector on the day. Upon arrival a male member of staff and five service users greeted the inspectors. The registered manager arrived later, at approximately 10.15am and then assisted the inspectors throughout the rest of the inspection. Prior to this inspection the registered manager informed the Commission one service user had been admitted to hospital following an incident. A copy of the Regulation 37 report was submitted. Prior to the manager arriving at the home the service users were observed making breakfast, completing their daily chores, interacting with each other and taking their medication. The inspectors had a lengthy conversation with the carer and the service users during this time. The home’s pre-inspection questionnaire report and comment cards were received prior to this inspection. Comment cards received were from each of the service users who reside in the home and one from the GP who did not make any comments. Comments cards read were very positive. One service user stated ‘lovely food, great support from staff. They enjoyed swimming twice a week with other residents from the house. They also enjoyed walking 20minutes after lunch, as they are on a healthy routine and also they enjoy doing chores in the house where they live in.’ other comments stated that ‘they are happy living at Roseview.’ The rest of the inspection involved, sampling a number of care plans, records a tour of the building and observing staff interaction with the service users, which was friendly, respectful and caring. The manager, staff and service users the inspectors met were very open and helpful throughout the inspection. The inspectors would like to thank them for their co-operation. 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 independent and are supported appropriately by the staff when needed. The service users spoken to stated that like living in the home. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: This inspection has identified twenty areas of improvement and three recommendations. Two of the areas of improvement from the previous inspection have been restated in this report. One Immediate Requirement notice was issued. Relating to the registered person ensuring that at all times there are two members of staff on each shift. Following on from this, it is therefore required that the registered person submit an action plan to the Commission for Social Care Inspection (CSCI), which describes how they will address these matters. The action plan must describe how the registered person ensures: • That on each shift there must be two members of staff who are competent, qualified and experienced to work with the service users living in the home • That on each shift there is a qualified first aider and that this must be highlighted on the rota in place. • That an appointment is made with the GP or the Dietician regarding the specific service user whose blood sugar levels are high. Guidance notes must be in place for all care staff when taking a blood sugar level and urine test and all care staff must be trained on how to complete the blood sugar and urine test correctly. • All paper towel dispensers must have a supply of paper hand towels. • Clear guidance must in place for one specific service user whose cigarettes has now been reduced. Guidance notes must be in place on how this is implemented, monitored and reviewed. • All new care staff must complete an induction training, evidence of this must be kept on individual care staff file • All fire doors must not be wedged open, consultation with the London Fire Emergency Planning Authority (LFEPA) with regards to the safety aspect of fire doors and magnetic devises must be sought and advice acted upon. • An annual environmental and fire risk assessments are to be completed • Control of Substance Hazardous to Health (COSHH) items are to be kept in a locked cupboard Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 7 • • • • Bedroom 2 is to be redecorated and the ceiling in the shower room is to be repaired The registered person must ensure that the specific service user who requires a chiropodist, has an appointment made and a clear record of the action taken is documented The registered person must update and review the current training needs for each individual care staff. All medication that needs to be stored in a fridge must not be stored with food. A separate fridge, which is lockable, must be sought for this purpose. The three recommendations stated in the table at the back of the report are deemed a good practice. The requirements made at the last inspection that have not yet been met and have been restated in this report, with a new timescale of compliance. In the ‘Timescale for Action’ column, the date in ordinary type relates to the timescales given the last inspection. The date in bold type relates to the new timescale. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. 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.V265384.R01.S.doc Version 5.0 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.V265384.R01.S.doc Version 5.0 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): 3 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 present one service user is in hospital having their mental health needs reassessed. The indication from the manager is that the service user may not be returning back to the home. A Regulation 37 report has been submitted to the Commission prior to this inspection regarding this specific service user. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 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 Service users care plans are in place and have a detailed account of individual’s assessed and changing needs. However, this is not always consistently reviewed or monitored by the care home ensuring that individual’s care needs are being appropriately met. 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. One service user during the inspection needed constant reassurance and was tearful at times. The manager stated that this specific service user’s cigarettes had been reduced starting from the day of the inspection. From one every hour to one every two hours, and the reason for the change relates to the recent health check results by the GP which indicated that the service user has high blood pressure, high cholesterol and coughs and wheezes a lot more than usual. The manager stated that this has been discussed with the service user’s Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 11 relatives, who have agreed this change. However, there was no evidence, guidance or records of the recent discussion with the service user or their relative regarding this matter. It was advised that any changes to any individual’s healthcare needs must be recorded to ensure all care staff are aware of the changes. Clear guidance notes must be in place. This must be monitored and reviewed regularly. The manager must ensure that any discussion with service users and relatives with regards to any changes to their health care or daily routine is recorded. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 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 & 17 Service users are able to participate in appropriate activities within the community independently and sometime with support. Service users relationships are positive and good. The service users are happy with the meals provided by the home, however, health and safety within the kitchen areas is not always maintained. Therefore service users can be placed at potential risk from harm. EVIDENCE: Five service users were present in the home. The inspectors arrived just before breakfast and all service users were up washed and dressed. During the course of the inspection a number of service users went out on various activities. One service user went to the local shop to buy some ingredients for lunch. It was evident from the discussion that all the service users have a good rapport with one another. They prepare breakfast, cups of teas for one another and information on their likes and dislikes. Several service users offered the inspectors a cup of tea, which they made. The records indicate that service users lead quite independent lifestyles. They have keys to the front door and their bedrooms. There are few restrictions Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 13 imposed, and a service user stated that they were always treated in a dignified manner and staff respected their privacy. One service user stated that they like the meals in the home and one stated differently. They confirmed that their preferences regarding meals served had been responded to, this was observed. The kitchen area was examined. It was evident that there were a sufficient amount of plates, cups, cutlery and pots and pans in place. The kitchen had a separate hand-washing sink, however, there were no paper towels in place. This was also evident in one of the toilets seen during the tour of the building. The manager stated that in the past service users had taken the paper towels out and placed them in the toilet, blocking the system. It was advised that a roller towel holder could be introduced. This would enable service users to dry their hands at their own leisure and the issue of paper towels blocking the toilet system would be eliminated. It was advised this system should to be reviewed if introduced. In one of the kitchen cupboards examined there was a chip fryer with used cooking oil in it. The manager stated that one of the service user’s likes from time to time to fry their own foods and completes this task on their own. It was advised that the managers remove the fryer, as it is a potential fire risk and purchases an electric fryer that is safer for the service user to use at their own leisure. A risk assessment regarding specific service user using the fryer must be in place. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 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): 19 & 20 Service users healthcare and personal support needs are addressed by the home. However, this is not always appropriately maintained, reviewed or monitored appropriately. Therefore service users healthcare needs could be at risk from not being fully met. The medication is well managed therefore promoting good health. However, the health and safety procedure around medication storage is not always complied with safely. EVIDENCE: Individuals are treated with respect, privacy and dignity in the home. At the previous inspection one-service user had been diagnosed with diabetes. The care co-ordinator at the time stated that the specific service user does not always stick to a healthy eating programme and sometimes binges on other snacks, which are deemed unhealthy. It was evident at this inspection that the service user looked much more healthy and in discussion with the service user it was evident that the service user was trying to stick to a healthier diet. Upon reading this specific service user’s care plan it was evident that guidelines were in place with regards to the service user’s diabetic control and what foods were deemed healthier for the individual. Records show that the manager has consulted with the dietician. It was advised by the dietician that the home must complete weekly blood sugar level and urine tests. Records in place indicate that these are completed. The inspectors asked the manager at Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 15 what level does the care staff liaise with the dietician or GP if the service user blood sugar level or urine tests are high, and what is deemed normal. It was evident from the discussion that the manager was not aware of what these were. The records in place indicated that over a three-week period the individual’s sugar levels were very high (12 ). The manager stated that this was because the service user informed the staff that they had been eating foods within that period that had a high sugar and fat content. However, the following week this remained high. It was advised that the registered person must have in place proper guidance notes with regards to recording, monitoring and reviewing the specific service user’s blood sugar and urine tests completed. Only care staff that have undertaken the training by an appropriate qualified person to undertake this task. A record of when any such training was undertaken must be on file. It was required at the previous inspection that the registered person ensures that the specific service user who requires a chiropodist has an appointment made. A record of the appointment made was on file for the 4/7/05 and 7/10/05. However, it was evident from the service user’s feet that inadquate treatment had been given. Therefore this requirement is restated and it is required that a clear acount of what treatment was had must be recorded. Prescribed Colegen dietary supplement was found stored in the fridge and various prescribed medication was being stored on the shelve in the office. It was advised that any medication that needs to be stored in the frigde can not be stored with food and that a separate frigde must sought. The refrigerator temperature must also be monitored and recorded daily to ensure it is maintained between 2-8oC. All medication must be stored in a locked facility. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 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): 23 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: It was evident that all the carers employed in the home had recently undertaken adult protection training, except the new employee whom was on shift at the time. The inspector was not able to ask staff their understanding of adult protection. Since the previous inspection there has been an incident regarding one of the service users and a member of staff. The police were called and a Regulation 37 report was submitted to the Commission. The service user is still in hospital being reassessed regarding the service user’s mental health care needs. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 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, 25, 27 & 30 The home is reasonably clean and comfortably maintained ensuring service users have a secure place to live. However, the registered person has not addressed a number of minor maintenance areas of repairs or replacements. Therefore the service users’ home could be deemed unsafe with areas of a potential risk hazard if not satisfactory addressed. EVIDENCE: 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 users. During the tour of the building it was evident that the maintenace of the home was in need of constant montoring and review. It is advised that as part of the Regulation 26 visits this must completed in full detail as at present this is not done. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 18 It was evident that the service user’s rug had been replaced, athough the manager stated that there is still an issue with regards to the service user smoking in their bedroom. The carpet in the lounge had not been replaced. The capert is lifting and is uneven in places an is deemed a potenial hazard. At a previous inspection this was raised as a requirement. The manager stated that this would be replaced in three months along with a number of other areas of maintenance identified within the organisation as a whole. It was advised that the stair carpet must be included in this works programme. It was also evident that the lounge/diner areas needed redecorating (walls needed painting). The laundry area is positioned under the stairs. It was evident that the pipes tp the left hand side on entering the area were exposed and must be boxed in. The hand basin taps were able to swing around when turned on. It was advised that these must be replaced or made secure. The manager stated that service users do their own washing and that this was the reason for the box of soap powder being left in the laundry area. The Control Of Substance Hazard to Health (COSHH) cupboard was positiioned in a cupboard next to the laundry area, which was found to be unlocked. It was advised that all COSHH items such as soap powder must be kept in a locked cupboard at all times. Other areas that needed addressing were bedroom two which was in need of redecoration and the shower room had a crack in the ceiling that needed repairing. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 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): 33, 35 & 36 The registered person has failed to ensure that an effective, competent and qualified staffing team supports service users on a daily basis. The registered person has also failed to ensure that appropriate staffing levels are appropriately maintained. Therefore placing service users at potential risk from harm. EVIDENCE: A copy of the rota was on the office notice board. At the previous inspection it was required that the registered person ceases the practise of care staff sleeping on the sofa in the lounge when completing a sleeping-in duty. Prior to this inspection the registered person submitted an action plan to the Commission stating that this shift is now being covered by a waking night duty. On each night shift two waking night staff were rota’d on. It was also required at the previous inspection that the registered person reconsiders the employment of the young person who was working in the home. Prior to this inspection a letter was submitted from the registered provider to the Commission stating that the young person employment had now ceased. Upon arrival there was one male carer supporting five service users, two of whom are female service users. The carer informed the inspectors that he has Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 20 recently started employment with the organisation. The carer also informed the inspectors that he had just completed a waking night shift by himself and was now completing the early shift. The question was asked as to why this was the case, as the rota seen clearly indicated that there were two waking night staff rota’d to complete the shift (whom were female). The carer stated that the two carers rota’d to complete the waking night shift rang in sick and the on-call manager asked him to complete the night shift. It was also evident that the member of staff had completed an early shift the day before. From the discussion with the carer it seemed as if the carer had not gone home since working the early shift. This was discussed at length with the manager. The manager also informed the inspectors that on the days she and the care coordinator are rota’d on they are not always present in the home, because of appointments for service users or other office things that cannot be completed in the home. The staff member rota’d on with the manager or the care coordinator can be contacted on their mobile phones regarding any issues that might arise. This was concerning, as there were a number of shifts highlighted on the rota where the manager and the care co-ordinator was the second carer on shift. The manager stated that the rota is drafted by the care co-ordinator. The manager and the care co-ordinator make any neccesary changes that may accur. Past rota’s were examined. It was evident that no changes had been recorded. It was also evident from the discussion that the manager did not seem to know or was not fully aware of the importance of ensuring that the rota in place must record an accurate reflection of the shift completed by the care staff employed. (Although this was a requirement from the previous inspection.) It was advised by the inspectors that the registered manager must be available in the home on a full time basis. Failure to do this will inevitably impact on the manager’s effectiveness and in turn may affect the quality of care offered to the service users. An Immediate Requirement was issued regarding that there must be two members of staff on shift at all times and this must be clearly indicated on the rota. Personnel records were requested and examined. It was evident that the carer on shift personnel documents was not in place in the home. The manager stated this was kept at head office. The two staff records examined were found to be in good order. However, one file did not have any evidence that an induction programme had been completed and the last recorded supervision notes completed was for September 2005. For those staff that had undertaken first aid training, certificates were seen. However, it was evident that the certificates in place were for basic first aid training. It was advised that on each shift there should be one member of staff who holds a qualified first aider certificate. The registered person has written to the Commission to request a reduction in reduces the number of waking night care staff from two to one carer during the night. At present the home is supporting five service users. A meeting regarding this issue has been arranged by the Commission with the registered Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 21 manager and the provider to discuss this matter further. Until then it is required that the registered person must ensure that at all times the night shifts are covered by two care staff until. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 22 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): 42 Service users health, safety and welfare are not being regularly reviewed and monitored. Therefore, the registered person has failed to fully protect service users with regards to their health and safety. EVIDENCE: During the inspection the fire security engineer visited to check all the fire extinguishers in place. Part of the inspection process included the inspectors completing a fire risk assessment whilst touring the building. The purpose of the fire risk assessment was discussed with the manager. It was identified through the fire risk assessment that there were a number of good practices and some areas of concern. All the fire extinguishers are in place and the means of escape is clear. However, the lounge door and the interconnecting doors from the lounge to the hallway were all found to be wedged open. It is advised that the manager completes a thorough environmental and fire risk assessment which is reviewed and monitored annually. Appropriate action must be taken in respect of fire doors that continue to be propped open, therefore rendering the Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 23 self-closing device inoperative. It was also advised that consultation with the London Fire Emergency Planning Authority (LFEPA) is to be sought and any advice given acted upon. It was evident that the manager had already completed a risk assessment on the fire doors, which were seen by the inspectors and found to be satisfactory. However, this needed to be expanded to inculded a detailed fire risk assessment of the home. Another area of concern related to the fire panel; it did not indicate what each zone represents. All this was discussed at length with the registered manager in the feedback session at the end of the inspection. Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 X 2 X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 1 X 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Roseview Home Score X 2 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000010752.V265384.R01.S.doc Version 5.0 Page 25 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 YA33 Regulation 18(1)(a) Requirement The registered person must ensure that at all times there are two members of staff who are suitably qualified and competent, on each shift. If a member of staff is off sick or on leave appropriate cover must be sought. The rota must indicate clearly staff sickness this includes training and annual leave by 9th January 2006. Immediate Requirement The registered person must ensure that each night shift there are two members of staff working until the Commission is satisfied that the registered person has ensure that all the health and safety aspect of ensuring that the service users are safe at night are in place. The registered person must ensure that on each shift there is a qualified first aider. The named care staff must be indicated clearly on the rota. Past copies of rota’s must be kept for the purpose of the inspection. DS0000010752.V265384.R01.S.doc Timescale for action 09/01/06 2. YA33 18(1) 23/01/06 3. YA42 13(4) 28/02/06 Roseview Home Version 5.0 Page 26 4. YA19 13(1)(b) 5. YA19 13(2) Sch 3.3m 6. YA30 13(4) 7. YA17 13(4) The registered person must check that the first aid training currently provided is equivalent to an HSE approved course in administering first aid at work. In accordance with NMS 42. The registered person must make an appointment with the GP or the Dietician with regards to the current blood sugar levels for a specific service user. The registered person must ensure that the specific service user, who has their blood sugar level and urine test completed weekly, has in place on their care plan, clear instruction by the relevant professional as to how this is undertaken. The guidance note must include how this is recorded, monitored, reviewed and what action is to be taken if the blood sugar level and urine test indicates a change. Consent given by the service user or their representative on their behalf with regards to care staff completing this task must be in place. Only care staff that are appropriately trained can complete this task. Should list of all trained care staff is to be placed on the front of the specific service user’s Medication Administration Records chart (MAR), with the dates of training undertaken. The registered person must ensure that the paper towel dispensers have at all times a supply of paper towels. (Previous timescale of 30/08/05 not met.) The registered person must cease using the deep fat fryer that is in place. DS0000010752.V265384.R01.S.doc 20/02/06 28/02/06 31/01/06 31/01/06 Roseview Home Version 5.0 Page 27 8. YA6 9. YA35 10. YA42YA24 11. YA42 The registered person must have in place clear guidance notes with regards to how the specific service user’s cigarettes are to be reduced. The guidance notes must include how this is implemented, monitored and reviewed. The service user or their representative on their behalf must be consulted at each step and a record of this is to be kept. 18(1)(c)(i) The registered person must ensure all new care staff have undertake a clear and precise induction programme that relates to the health and safety and welfare of the service users in the home. Evidence that this has been undertaken must be on each care staff personnel file. 13(4)(a)(b) The registered person must ensure that all fire doors are able to effectively self –close at all times and are not wedged open. (Previous timescale of 30/08/05 not met) 23(4) Magnetic door hold or a release 13(4) mechanisms must be fitted to any fire doors in the home that young people/staff members routinely prefer to leave open for extended periods of time during the day or night. Alternatively, the registered person must consult with the London Fire Emergency Planning Authority (LFEPA) fire officer with regards to risk assessment with regards to the safety aspect of fire doors and provide evidence that LFEPA are satisfied with fire doors being propped open. 12(2)(3) 20/02/06 28/02/06 31/01/06 28/02/06 Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 28 The registered person must have in place on the fire alarm panel a zone map that indicates clearly what each zone represents The registered person must complete an environmental risk assessment that includes a fire risk assessment. This is to be reivewed annually. The registered person must replace the carpet in the lounge/dining area. (Previous timescale of 30/08/05 not met) The registered person must either replace or thoroughly clean the staircase carpet. The registered person must ensure that the exposed pipes in the laundry area are boxed in ensuring access can be made if needed. The registered person must ensure that all Control of Substance Hazardous to Health (COSHH) are kept in locked cupboard. The registered person must redecorate the lounge and bedroom 2 areas. The registereed person must ensure that the shower room ceiling is repaired. The registered person must ensure that the specific service user who requires a chiropodist has an appointment made. A record of the appointment is to kept the on specific service users care plan and what action was taken. The registered person must ensure that all service users healthcare needs are addressed DS0000010752.V265384.R01.S.doc 12. YA24 13(4) & 23(2)(d) 13/03/06 13. YA30 13(4) 28/02/06 14. 15. 16. YA25 YA27 YA19 23(2)(d) 23(2)(d) 12(1,b)Sch 3.3(m) 28/02/06 28/02/06 20/02/06 Roseview Home Version 5.0 Page 29 17. YA35 18(1)(c)(i) 18. YA36 18(2) 19. YA33 WTD 1998 recorded and monitored appropriatley. (Previous timescales of 16/08/05 was not met.) The registered person must review each of the care staff training and development needs. Training such as fire awareness, food hygiene, first aid and manual handling must be reviewed. The registered person must ensure that supervision must be completed at least six times a year. For those care staff who have recently started employement this must be included as part of their induction programme. The registered person must ensure that care staff have appropriate breaks, indicated on the rota. 30/03/06 20/02/06 31/01/06 20. YA20 13(2) The registered person must ensure that any care staff working over and above the allocated hours per week required under ‘The Working Time Directive’s’ must be reviewed with each staff member and a copy of the their agreement or non agreement must be kept on their individual’s file. Working Time Directive 1998 The registered person must 20/02/06 ensure all prescribed medication that clearly states ‘to be stored in the fridge’ is stored in a separate fridge and not in the same fridge with food. The registered person must obtain a lockable fridge to store medication. The refrigerator temperature must also be monitored and recorded daily to Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 30 ensure it is maintained between 2-8oC. The separate fridge that stores all prescribed medication must a lockable cabinet. 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. Refer to Standard YA30 YA6 Good Practice Recommendations The registered person should review the current paper towel dispensers and put in place roller towels. It is recommended that the registered person should reduce the specific service user’s cigarettes daily, as this would enable the service user to get used to the reduced amounts now being given. It is recommended that the registered person replace the deep fat fryer with an electrical fat fryer, as the inspector is of the view that this is deemed safer 3. YA17 Roseview Home DS0000010752.V265384.R01.S.doc Version 5.0 Page 31 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.V265384.R01.S.doc Version 5.0 Page 32 - 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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