Inspection on 04/05/06 for Rosina Lodge

This inspection was carried out on 4th May 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 but made no statutory requirements on the home.

Other inspections for this house

Rosina Lodge 03/05/07

Rosina Lodge 09/01/06

Rosina Lodge 23/06/05

Rosina Lodge 14/12/04

Rosina Lodge 21/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Rosina Lodge 76 St Augustine`s Avenue South Croydon Surrey CR2 6JH Lead Inspector Peter Stanley Key Unannounced Inspection 4th May 2006 9:30am 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 Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 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. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rosina Lodge Address 76 St Augustine`s Avenue South Croydon Surrey CR2 6JH 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 8760 0735 020 8760 0735 rosina@blueyonder.co.uk Mr Balasubramaniam Balachandran Mrs Ginige Pearl Srimatie Balachandran Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: Rosina Lodge provides places for up to 19 older people in a large converted detached family home in a very pleasant residential road in South Croydon. The home has a pleasant grassed garden to the rear with flowerbeds. The frontage is tree-lined with conifers and tarmac’d, providing standing for a number of vehicles to park off-road under a fine spreading Canadian Redwood tree. Public transport is a walk away on the Brighton Road (frequent services) or closer (but less frequent) service is also available on Pampisford Road. The home is a three-storey building with seventeen bedrooms, two of which are for double occupation, the remainder singles. All floors are accessible, via a passenger lift. The manager’s office is sited on a half-landing between second and third floors. All main public rooms (Dining room/ through Lounge and a separate smoking room) are provided at ground floor level with the addition of a small sitting / quiet room on the first floor. Both the kitchen and laundry are at ground floor level. The proprietors are hoping, in due course, to build a conservatory adding - at the same time - a covered link to the laundry (which currently has no internal access route - save for the smoking room). Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There are currently 17 service users resident at this home, with 2 vacancies. This unannounced inspection was conducted over one day and involved discussion with the registered providers, Mr and Mrs Balachandrun, with staff members on duty and with service users. The inspector spoke to a large number of service users during the course of this inspection, and case-tracked four recent admissions to the home. Relevant documentation including staff and service user files, policies and procedures, staff rotas and logs relating to incidents, accidents and complaints, were examined. The inspector carried out an inspection of the premises and observed staff’s interactions with service users. The home does not currently have a registered manager. Mrs Balachandran, one of the two registered providers, is fulfilling this role. She is studying for an appropriate management qualification in residential care, with view to applying to the CSCI (Commission for Social Care Inspection) to become the registered manager. The providers provided an assurance that Mrs Balachandran is close to completing her studies and that she will shortly be applying to become the registered manager. From this inspection there are 14 requirements. This includes 6 requirements which remain to be met from the previous inspection. What the service does well: Each service user is being provided with a copy of their contract or terms and conditions at the point of moving into the home. The format has been revised so as to make it more comprehensible for service users. The home is able to demonstrate that the range of needs presented by service users is being appropriately met. The health care needs of service users are being fully met. Service users are having their health, personal and social care needs set out in an individual plan of care, with review taking place on a monthly basis. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 6 Service users feel that that they are being treated with respect and that their right to privacy is being maintained. The views and wishes of service users, and those of their relatives, regarding the eventuality of their illness and death, are being respected. Training in bereavement and loss is being planned for staff. Service users are being provided with opportunities for recreational and social activities sufficient to meet their existing needs. Service users are encouraged to maintain contact with their family and friends and to retain links with the local community. Service users are assisted to exercise a fair degree of choice and control over their day-to-day routines and decision-making. The meals provided are wholesome and appealing and are served at times, and in places, which are convenient to them. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are able to raise any concerns they may have. The legal rights of service users within the home are being protected and promoted. Service users are being encouraged and assisted to vote if they wish. Service users are evidenced to live in a safe, well-maintained environment, with access to safe and comfortable facilities. Risk assessment of the home and individuals are in place for their protection. Service users have access to safe and comfortable communal facilities. Sufficient bathing and toilet facilities are currently in place, though any increase in the number of service users requiring assisted baths may require additional facilities to be provided. Sufficient aids and adaptations are in place to safely meet the needs of service users. Service users’ rooms were observed to be safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. The home presents as clean, pleasant and hygienic. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The home is on track for meeting the target of 50 of staff with NVQ Level 2. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 7 Generally, staff are being provided with the necessary induction and training with which to perform their work duties competently, and safely meet the needs of service users. Service users’ interests are being protected by the regular supervision of staff, and annual staff appraisals. What has improved since the last inspection? What they could do better: An up-to-date inspection report must be included in the service user’s pack. While the home’s policies, procedures and practice indicate that service users are generally being protected from abuse, their protection also requires that all remaining staff (who have not yet done so) attend statutory adult protection training, and that the home’s procedure for reporting allegations is amended to make reference to the Local Authority’s Vulnerable Adults guidance and procedures. While service users can feel assured that the registered providers are presently managing the home in a competent way, the need for day-to-day managerial control and accountability necessitates the early appointment of a registered manager. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 8 The management approach was observed to be conducive to creating an open, relaxed and friendly atmosphere. However, while service users feel that the home is being run in their best interests, their involvement in the home’s consultation and decision-making processes must be evidenced with regular service user meetings. The Home’s Business Plan must be reviewed and updated, and a copy forwarded to the CSCI. The registered providers must obtain a set of audited annual accounts for the financial year ending 2005. 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. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 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 Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 5 Service users are now being provided with all the information they require to enable an informed choice as to where they would like to live. However, an upto-date inspection report must be included in the service user’s pack. Each service user is being provided with a copy of their contract or terms and conditions at the point of moving into the home. The format has been revised so as to make it more comprehensible for service users. The home is able to demonstrate that it is assessing the needs of prospective service users, and that care management assessments are now being obtained prior to admission. The home is able to demonstrate that the range of needs presented by service users is being appropriately met. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 11 EVIDENCE: The home has compiled a statement of purpose outlining the aims and objectives of the home, and the facilities and services it provided. This has been expanded to include all the information detailed in Schedule 1 of the Care Homes Regulations (2001). The home has developed a service user’s guide; this has been expanded to include all elements of Standard 1.2. All service users have now been issued with a revised copy of the home’s service users’ guide. An out-of-date inspection report from June 2004 was included in the service users’ pack. The inspector is making it a requirement for an up-to-date inspection report to be included. Prospective users are invited to visit the home and to move in on a trial basis, based on their needs and choice. Staff visit prospective service users in their own home or current setting wherever possible, so as to gain as full a picture as possible of their needs and lifestyle. The Registered Providers are keen to ensure that new service users are compatible with existing service users. The home does not accept emergency admissions or provide intermediate care. The home has developed a contract that is more user friendly, being written in an appropriate format/language. The inspector examined a sample of contracts. Following a requirement from the previous inspection, these are now being signed by the service user or his representative, and state the number of the room to be occupied. Since the last inspection there have been four new admissions to the home. The inspector examined the service users’ files and found that contracts are now being been drawn up between the home and the service user. This meets a requirement from the previous inspection. The home is required to obtain a full care management assessment and care plan from any service user’s referred by a local authority, and to undertake an assessment with the service user, relative or delegated representative, and with any relevant professionals that have been party to the referral. The inspector examined the files for the four new admissions and found that for the three service users admitted under care management arrangements, the relevant care management assessments had been obtained from the referring agency. The relevant pre-admission assessments, risk assessments and care plans had also been completed by the home. For the other admission, Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 12 a privately funded hospital admission, hospital assessments had been obtained, and the relevant assessments and care plan completed. Both requirements from the previous inspection have therefore been met. The home’s capacity to meet the assessed needs of individuals admitted to the home is evidenced as being met. Also, that the specific social and cultural needs of service users are being identified and addressed. The inspector spoke to a large number of service users. This indicated that most service users feel broadly satisfied with the care and support being provided at the home, and believe that their needs are being appropriately met. The inspector spoke to a service user from a minority ethnic group who felt that his specific dietary and cultural needs were being met. Some comment was, however, received which indicated that standards of care could vary, and that, where there is a perception of some-one being ‘demanding’ staff are not always as receptive and respectful as they might be. Evidence from care reviews indicates that service users are being involved in decisions relating to their care and that their needs are being satisfactorily identified and addressed. A sample of service users’ care plans were inspected and found to have been regularly reviewed on a monthly basis. Staff were evidenced to have been provided with the relevant induction and training, and to possess the relevant skills and experience with which to deliver the service to a satisfactory standard. A key worker system is in operation. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 11 Service users are having their health, personal care and social needs set out in an individual plan of care, with review taking place on a monthly basis. The health care needs of service users are being fully met. Service users are being safeguarded by the home’s medication policies and procedures. All but one staff member has completed accredited medication training. Service users feel that that they are being treated with respect and that their right to privacy is being maintained. The views and wishes of service users, and those of their relatives, regarding the eventuality of their illness and death, are being respected. Training in bereavement and loss is being planned for staff. EVIDENCE: Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 14 Care plans are compiled on the basis of the initial assessment prior to admission, on admission and during residency. Four service users recently admitted to the home are evidenced to have had care plans put in place. These include a photograph of the service user, and set out the individual needs of each service user and how the home aims to meet these. Sampling of care plans indicate that these are being reviewed and recorded on a monthly basis. Following a previous requirement, 8 staff have received relevant training in carrying out risk assessments, but a further 6 staff have yet to complete this; hence the requirement for risk assessment training still applies. The home is attached to a GP practice. The practice has not, however, been able to accept some of the more recent admissions and these have been allocated to a GP from a different practice. The inspector was informed that there are no longer any regular routine visits to the home, and that GPs and district nurses attend service users as and when required. While not ideal, this is a health care issue that is outside of the Home’s control. Other health care professionals, including a chiropodist, visit on a periodic basis. Generally, service users who spoke to the inspector were satisfied with the health care that they have received. One service user is currently receiving visits from a district nurse for treatment for a swollen leg; the service user felt that this had been appropriately identified and followed up by the home. No health care concerns were identified. The home has a medication policy in place. Blister packs are used and kept in a locked cupboard in the providers’ office. No controlled drugs were in use at the home at the time of inspection. The inspector examined a sample of service users’ medication records and found these to be satisfactorily maintained. Following a previous concern, MAR sheets are now being kept up-to-date and accurate, with staff signing the MAR sheets to indicate that medication has been given. The receipts and disposals record was also examined and found to be satisfactory. The pharmacist visits regularly to do a medication audit, his most recent visit being on 10 February 2006. He found the home’s recording to be satisfactory. A number of recommendations, including the need to include a recent photograph of the service user on each MAR sheet, have been implemented. A requirement from the last inspection, for all staff that administer medication to complete accredited medication training, has now been nearly met. 1 staff member is due to complete this training, training having been booked for 27 June. Training has now been evidenced with certificates. Generally, staff were observed to respect the privacy and dignity of service users, and to be interacting in a respectful and professional manner. The inspector spoke to a large number of service users. Most service users felt Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 15 their privacy was being respected and indicated that they are able to see visitors in their own rooms if they wish. There was, however, some feedback, which indicated that staff were not always as respectful as they might be, and that staff attitudes towards service users perceived as ‘demanding’ could, at times, be negative. This will be monitored on future inspections. In the shared rooms curtains are available to screen off the shared areas when care is being given. Neither of the double rooms is being shared at the current time. Since the last inspection, there has been one death of a service user at the home. The home has a policy on death and dying. The service users family and friends are involved (if that is what the service user desires) in planning and dealing with infirmity, terminal illness and death. A Catholic priest visits regularly and there is the opportunity for service users who wish for contact with a Church of England minister, to do so. The religious and spiritual needs of service users from other faiths are addressed in accordance with the expressed wishes of the individual. Following a requirement from a previous inspection, the home is now recording service users’ wishes concerning the eventuality of their serious illness or death. These are being noted on a separate record, with a summary of these needs being recorded in the service user’s care plan. The home has arranged for staff to receive bereavement training on 24/5/06. This should prove beneficial in enabling staff to offer appropriate support to service users when bereavement or loss occurs. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 to15 Service users are being provided with opportunities for recreational and social activities sufficient to meet their existing needs. Service users are encouraged to maintain contact with their family and friends and to retain links with the local community. Service users are assisted to exercise a fair degree of choice and control over their day-to-day routines and decision-making. The meals provided are wholesome and appealing and are served at times, and in places, which are convenient to them. EVIDENCE: Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 17 The home offers a range of activities that includes bingo sessions, painting, and music/movement therapy. There are visiting entertainers who visit twice a month, which includes musical sessions and sing-a-longs. There is also an exercise session organised once a fortnight. During the inspection some service users were gathered in the ground floor communal lounge where they were interacting positively with staff. Service users spoken to by the inspector indicated that they enjoy considerable flexibility in their routines and are able to visit the local shops, parks and community facilities. The inspector was informed that 7 service users and 4 staff went to the Fairfield Halls for a Christmas pantomime, and that an outing to the seaside is currently being planned. There are no restrictions unless there are concerns regarding a service user’s own personal safety. Staff often accompany service users when accessing activities in the community. There are also various local church activities which service users attend, summer barbecues in the garden, and organised outings to places of interest. Visitors to the home are actively encouraged and welcomed. Feedback received from service users was generally very positive. This indicated that the home is welcoming to visitors and that relatives and friends are able to visit when they wish, with privacy for visits being respected. Service users spoken to during the visit expressed their satisfaction with the way the home is run, and indicated that they are able to exercise a fair measure of personal autonomy and choice. The inspector was, however, concerned to find that service users’ meetings are not being held on a regular basis, the last two meetings having taken place on 24/9/06 and 17/3/06. The registered person must ensure that regular service user meetings are held on at least a two-monthly basis. A requirement applies. The inspector was advised that four service users are entirely involved in dealing with their own financial affairs, including collecting their pensions. Others have assistance, generally from relatives or close friends. The home handles monies for service users only when a local authority has an agreement that the home will act as the ‘conduit’ for the payment of personal allowance. Records are maintained on behalf of 3 service users, where relatives periodically provide monies for personal expenditure. These were examined and found to be in order. Advocacy services are known of and publicised at the home. The inspector spoke to a number of service users in the dining room at lunchtime, and observed food that had been prepared. Service users once again expressed very positive comments regarding the quality of food that is served, and there was evidence of choice of dishes. The inspector spoke to one service user who is a vegetarian, who said that her dietary needs are being met. Also, one service user from an ethnic minority group stated that the home was usually able to meet his food preferences. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 18 The home provides both English and Sri Lankan food, though most service users opt for the more traditional English fare. The food is home-cooked and provides a well-balanced and nutritional diet. This is evidenced in the home’s menus and in the observation of food being prepared and served to service users. The menus are changed on a regular basis and the food on offer is discussed with service users. Three meals a day are available, together with morning and afternoon teas. A copy of the day’s menu is placed on the notice board with alternatives being available if required. Service users are consulted in advance regarding their choice. While the dining room is able to seat all the residents comfortably, service users are able to take their meals in their rooms if they so wish. The home keeps a detailed record of all food consumed by the service users, and monitors their weight on weight charts. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 to 18 The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are able to raise any concerns they may have. The legal rights of service users within the home are being protected and promoted. Service users are being encouraged and assisted to vote if they wish. While the home’s policies, procedures and practice indicate that service users are generally being protected from abuse, their protection also requires that all remaining staff (who have not yet done so) attend statutory adult protection training, and that the home’s procedure for reporting allegations is amended to include the Local Authority’s Vulnerable Adults guidance. EVIDENCE: The home has an appropriate complaints policy and procedure in place. A complaints book at the home details the outcome of any complaint and what action (if any) was taken. The complaints procedure is clear and simple and includes the stages and time scales for complaints to be managed. While no complaints have been made since the last inspection, the inspector understands that all complaints are taken seriously and would be dealt with Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 20 promptly and effectively. The procedure has been amended so as to state that a complaint can be referred to the CSCI at any time. All service users are registered to vote, and are supported where necessary to vote, usually by postal vote, or by attending the polling station. Most of the service users have exercised their right to vote in the recent local council elections. The home holds information on advocacy services should they be required. Both Mind and Age Concern, in Croydon, provide this service. The home has obtained a copy of the Local Authority’s Procedure on the Protection of Vulnerable Adults. The home’s internal adult protection procedures have, however, still to be amended and updated to include the Local Authority’s guidance. The home has a Whistle Blowing Policy in place for staff to reference should the need arise. This has been developed to ensure it complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets. Most staff have attended statutory adult protection training, with 3 staff currently being on Croydon’s waiting-list for training. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 to 26 Service users are evidenced to live in a safe, well-maintained environment, with access to safe and comfortable facilities. Risk assessment of the home and individuals are in place for their protection. Service users have access to safe and comfortable communal facilities. Sufficient bathing and toilet facilities are currently in place, though any increase in the number of service users requiring assisted baths may require additional facilities to be provided. Sufficient aids and adaptations are in place to safely meet the needs of service users. Service users’ rooms were observed to be safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. The home presents as clean, pleasant and hygienic. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 22 EVIDENCE: The inspector completed an inspection of the premises, and spoke to a large number of service users. Positive views were expressed regarding the ‘homely’ and pleasant home environment, with residents indicating that they were happy with their rooms and with the communal facilities provided. The home has a planned programme of maintenance and development for the home. Rooms 11, 12, 13, 20 and 22 have had new carpeting fitted, with repainting and new carpeting in the corridors, and some redecoration in the lounge and dining area. New wall lamps have been installed in the lounge, giving a more domestic feel to the lighting. The registered persons are planning to build on a conservatory to the house, providing a new space to accommodate the few smokers at the home. The present smoking room would then be converted into an office. At the same time a link corridor will be provided across the front of the house to create an internal link with the laundry - an essential measure required to ensure best practice with regard to infection control. The home was assessed by an occupational therapist on 24 July 2004, with all requirements from this assessment having been met. These included placing restrictors on all upstairs windows, completing risk assessments for all service users who use the stairs, and the placing of warning signs on all doors that open outwards. The home has stair rails and rails fitted along corridors. There is a passenger lift to all floors. The home has a loop system for the television and telephone. Raised toilet seats, commodes and adapted bath chairs are in evidence throughout the home. The communal areas presented as very pleasant and homely. There is a spacious lounge, which is divided into two distinct areas, with a separate dining area. The lounge and dining room overlook a pleasant garden. The service users use this in the summer months. There are four bathrooms and five toilets spread throughout the home. No ensuite toilet or bathing facilities are available for service users. There are sufficient assisted baths provided at the home. It is accepted that not more than two assisted baths would be able to be given at any one time, as staffing would not allow this. With two staff on duty (and three at peak times) this is currently sufficient, but could become more problematic should the current numbers of service users requiring assistance increase. There are 15 single and 2 double rooms, both of which are currently being used as single rooms. Some service users, who were in their rooms, indicated that they were happy with their rooms, these reflecting their individual tastes Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 23 and identities, and including personal photos, mementoes and some items of their own furniture. Rooms are generally adequately furnished and pleasantly decorated. The inspector observed that the doors of two rooms were being wedged open; the inspector was advised that this was in accordance with the service users’ wishes. The manager was informed that this presented a fire risk and that magnetic doorstops must be installed on doors for Rooms 20 and 21, and on any other doors that are kept wedged open. In the meantime, risk assessments must be completed with the service users concerned. The home generally presented as clean, pleasant and hygienic, with kitchen, washing/toilet and communal areas being inspected. The Environmental Health inspector inspected the home on 8 February 2005, and recommendations implemented. A mechanical sluice / pan sterilising machine is separately located in its own room on the first floor, enabling access from all areas, without risk of cross-infection. The inspector inspected a number of service users’ rooms, which were generally being kept clean and hygienic. A previous requirement for regular 4weekly shampooing of the carpet in the room of one service user has been partially met with new carpeting having been installed, and occasional cleaning having taken place. While the service user did not raise this as a concern, the inspector was again aware of a strong smell of urine in the room. The registered persons must ensure that there is ongoing regular 4-weekly cleaning of the carpet and that a written record is maintained of when this is completed. A requirement applies. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The home is on track for meeting the target of 50 of staff with NVQ Level 2. Following recent improvements in the home’s recruitment procedures, service users can feel more confident that they are now being appropriately protected. Generally, staff are being provided with the necessary induction and training with which to perform their work duties competently, and safely meet the needs of service users. EVIDENCE: The home was evidenced to have the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The inspector checked the staff rota. A minimum of two staff is being provided at all times, day or night (both waking staff), with at least three staff being present at peak times in the morning. The extra staffing in the morning allows for some ancillary work without reducing from the two care staff being available to service users at all times. The home has purchased a TOPSS approved induction pack for all new staff. This has now been put into place and evidences that each staff member has completed induction training including health and safety, the values and principles of care, resident care, and key policies and procedures. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 25 The registered providers are keen to ensure that all staff have the opportunity to develop their knowledge and skills and to obtain an NVQ qualification. The home is currently on track for meeting the 50 target. Staff records evidence qualifications obtained by staff. These include statutory training in adult protection, and training in medication, food hygiene, first aid, fire awareness, infection control and manual handling. An annual staff training plan has been developed. Training for staff in bereavement and loss is being planned. Following previous concerns relating to the completion of CRB and staff recruitment checks, the home was reminded of its responsibilities in this area. The inspector examined the staff file of a new staff member and found that a CRB check, and all identity and employment checks, had been completed. A CRB had been obtained for another staff member previously recruited, for whom a requirement had been made at the last inspection. Staff files are now including a photograph of the staff member as required in Schedule 2 of the regulations. Given previous concerns, this area will be closely monitored on future inspections. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 26 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 38 While service users can feel assured that the registered providers are presently managing the home in a competent way, the need for day-to-day managerial control and accountability necessitates the early appointment of a registered manager. The management approach was observed to be conducive to creating an open, relaxed and friendly atmosphere. However, while service users feel that the home is being run in their best interests, their involvement in the home’s consultation and decision-making processes must be evidenced with regular service user meetings. Service users’ interests are now being protected by the regular supervision of staff, and annual staff appraisals. The home is developing its quality assurance processes, with view to evidencing that it is meeting its aims and objectives, and is being run in the best interests of service users. This needs to be consolidated, and an annual audit and Development Plan put in place. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 27 The home must demonstrate its current financial viability and produce an annual business plan. Service users’ financial interests are being safeguarded. Generally, the inspector is satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. However, up-to-date 12-monthly servicing of the Home’s portable electrical appliances must be completed. EVIDENCE: The registered persons took over the home in June 2003 with a registered manager of their selection joining them at the point of transfer to their ownership. This did not work out and the two proprietors have been managing the home. A further appointment was made in January 2005 but again this did not work out and the manager was asked to leave. Mrs Balachandran has a BSc in Print Technology Management & Research, and has skills in Counselling and Complementary Therapies - she has completed the CMS (Certificate in Management Studies). The inspector has been concerned at the length of time that the home has been without a registered manager. However, Mrs Balachandran has been studying for the relevant management qualifications of NVQ Level 4 and the RMA (Registered Manager’s Award) and has assured the inspector that she is close to completing her studies. A requirement applies. Mrs Balachandrun has, in the period since taking over the home, gained substantial experience of managing the home and has demonstrated a high level of commitment and competence in fulfilling this role. From the evidence of this inspection, and the feedback received from both service users and staff, the home is being managed in a competent, caring and open way. The inspector was, however, concerned that service users are not being fully involved in the consultation and decision-making processes within the home. Service user meetings are not being held on a regular basis, the two previous meetings having been held on 24/9/05 and on 17/3/06, a six-month gap. Service users must have the opportunity of attending meetings on at least a two-monthly basis; a requirement applies. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 28 Staff were evidenced to be having regular monthly meetings, with feedback from staff members indicating that they feel happy working in the home, and that the management style is felt to be supportive and enabling. The home has been developing its quality assurance processes. The inspector was shown questionnaires that have been completed with the home’s service users, the relatives/friends of service users, and ones for visiting care managers and other professionals. The home is yet to carry out an annual audit, the results of which should be made available to service users, their relatives and other stakeholders, and a copy forwarded to the CSCI, local office. In addition the home has still to put in place an annual development plan. Requirements apply. The home must demonstrate its current financial viability. The inspector was informed that accounts for the year ending 31/7/05, and a current Business Plan, are due to be published. A copy of the current Business Plan, once published, must be forwarded to the CSCI; a requirement applies. The registered persons ensure that the service users who wish to control their own money can do so. Those who are unable to do so have either a relative or a designated representative to assist and support them as required. The home maintains records of financial expenditure for three service users; these were examined and found to be satisfactorily maintained. The inspector sampled some staff files and found that staff supervision is taking place on a regular two-monthly basis. The practice of the home is for one of the registered providers and the senior care officer to supervise the staff. A structured format for recording supervision has been developed to ensure that all relevant issues relating to practice, performance and training/development are covered within supervision. The home is also completing annual staff appraisals, these being evidenced during the inspection. There is a requirement from the last inspection that has now been met, for the home to evidence that it is annually reviewing its policies and procedures. Mrs Balachandrun advised that all policies and procedures are being annually reviewed. A policies and procedures checklist, evidencing the date of their adoption and review has been evidenced. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 29 All maintenance checks including 12-monthly gas safety/central heating servicing (6/3/06), 3-yearly electrical wiring (5/6/04), 6-monthly hoist servicing for two bath hoists (12/05), and 12-monthly water supply and legionella (28/3/06) have been inspected and are up to date. The home’s lift is inspected every three months (16/2/06) in line with the LOLER regulations 1998. 6-monthly inspections of emergency lighting, fire alarms, fire safety equipment and the emergency call system have been completed on 2/2/06, records being available for inspection. Risk assessments for safe working practices have been completed. Health and safety risk assessments have been carried out for areas of risk including the premises, manual handling, drugs, COSSH and waste disposal, on 19.6.05. The registered provider must, however, ensure that up-to-date 12-monthly servicing of the Home’s portable electrical appliances is arranged, the last servicing being evidenced for 28/2/05. A requirement applies. Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 30 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 2 2 3 2 Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 31 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 OP1 Regulation 5(1)(d) Requirement A copy of the most recent inspection report must be included in the service user pack. Training in carrying out risk assessments is required for all those staff who have not yet completed this. The registered person must ensure that one remaining staff member completes and evidences accredited medication training. The home’s internal adult protection procedures must be amended and updated to include the Local Authoritys Vulnerable Adults guidance. While the home has a copy of Croydon’s adult protection procedures, reference to these must be included in the home’s own written procedures. 5 OP18 12(1)(a) The registered person must DS0000043469.V291844.R01.S.doc Timescale for action 31/05/06 2 OP9 13(4)c, 18(1)c 30/09/06 3 OP9 13(2) 30/09/06 4 OP18 13(6) 30/05/06 30/09/06 Version 5.1 Page 32 Rosina Lodge (b), 13(6) ensure that three staff who have not yet completed statutory adult protection training, do so as soon as places become available. The registered persons must ensure that magnetic doorstops are installed on doors for Rooms 20 and 21, and on any other doors that are kept wedged open. In the meantime, risk assessments must be completed with the service users concerned. 31/07/06 6 OP19 23(4)(a) & (c) 7 OP24 13(4)(c), 23(2)(d) The registered person must ensure regular 4-weekly shampooing of the carpet in the room of a service user who has problems with urinary incontinence. A record of carpet cleaning must be maintained. The registered person must complete her NVQ4 and RMA, and register with the CSCI to become the Home’s registered manager. The registered person must ensure that regular service user meetings are held on at least a two-monthly basis. The registered persons must complete a quality assurance audit report. This must detail all the feedback from surveys and other sources of feedback. The audit report must be made available to service users, their relatives and other stakeholders 30/05/06 8 OP31 9(1) (2) & 10(1) 31/07/06 9 OP32 12(2) & (5) 31/05/06 10 OP33 24(1)(2) &(3) 31/07/06 Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 33 A copy must be forwarded to the CSCI. 11 OP33 24(1)(2) &(3) The registered persons must produce an annual Development Plan. The Development Plan should collate all the feedback and information gathered from surveys and other sources, and identify those areas where the aims and objectives of the home are not being fully met, and the actions/plans proposed to address any deficiencies or improvements required. A copy of the Development Plan should be made available to service users, their representatives and other interested parties, and a copy forwarded to the CSCI. 12 OP34 25(1) & (2) 12(1) The Home’s Business Plan must be reviewed and updated, and a copy forwarded to the CSCI. A Policies and Procedures checklist, detailing the date of adoption and review of each policy and procedure, must be compiled. All policies and procedures must evidence that they have been annually reviewed. The registered provider must ensure that up-to-date servicing of the Home’s portable electrical appliances is arranged and evidenced. A copy of the servicing certificate must be forwarded to the CSCI. 31/07/06 31/07/06 13 OP36 31/07/06 14 OP38 13(4)(a) & (c) 30/06/06 Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 34 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 35 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Rosina Lodge DS0000043469.V291844.R01.S.doc Version 5.1 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!