Inspection on 09/01/06 for Rosina Lodge

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 but made no statutory requirements on the home.

Other inspections for this house

Rosina Lodge 03/05/07

Rosina Lodge 04/05/06

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 Unannounced Inspection 9th January 2006 9:30 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.V276179.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.V276179.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 8667 9578 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.V276179.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd July 2005 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 currently has 14 residents with 4 vacancies. 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 threestorey 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.V276179.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over half a day and involved discussion with the registered provider, Mrs Ginige Balachandrun, with staff members on duty and with service users. The inspector spoke to six service users during the course of this inspection, including one for whom concerns had been expressed. The inspector case-tracked two 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 a brief inspection of the premises and observed staff’s interactions with service users. The home does not currently have a registered manager. This is being managed by Mrs Balachandran, one of the two registered providers. 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 inspector is, however, concerned at the excessive length of time being taken to appoint a manager and will be looking towards enforcement action if this requirement continues to remain unmet. The home has a sizeable number of unmet requirements. 9 (out of 17) requirements remain to be met, or fully met, from the previous inspection. From this inspection there are 6 further requirements (and 1 recommendation), making 15 requirements in total. What the service does well: 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. Risk assessments, to safeguard service users, are being completed and reviewed with service users. 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. Service users have access to safe and comfortable communal facilities. Service users expressed presented as settled and satisfied with their environment. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 6 Generally, service users’ bedrooms presented as safe, comfortable and pleasantly decorated, and suited to their occupants’ individual needs. 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. The management approach was observed to be conducive to creating an open, relaxed and friendly atmosphere. Service users’ views indicate that the home is being run in their best interests. What has improved since the last inspection? What they could do better: Two service users have not been provided with a copy of their contract, detailing their terms and conditions, when moving into the home. The home has failed to obtain full information regarding the health and care needs of a recently admitted service user. Generally, the range of needs presented by service users is being appropriately met. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 7 While service users are being protected by appropriate policy and procedures for medication, their protection also requires that accredited medication training is extended to all remaining staff who have not so far undertaken this. The home’s policies, procedures and practice indicate that, generally, service users are being protected from abuse. To ensure safety, however, the home’s procedure for reporting allegations of abuse must be amended to include the Local Authority’s guidance. Whilst, generally, service users are being safeguarded by appropriate recruitment policy and procedures, a CRB (Criminal Records Bureau) certificate has not been obtained for one staff appointment. While the protection of service users has been provisionally assured with the completion of a POVA (Protection of Vulnerable Adults) First check, and the provider’s assurance of compliance with CSCI guidelines, relating to the staff member’s supervision and contact with service users, prior notification must be made to the CSCI (and agreement given) regarding any future staff appointment where a CRB certificate has not been received. 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 home needs to evidence that it is annually reviewing its policies and procedures. These must be signed and dated, and a policies and procedures checklist maintained. 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.V276179.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Following revision of the service users guide, amended copies have been provided to all of the home’s service users. Two service users have not been provided with a copy of their contract, detailing their terms and conditions, when moving into the home. The home has failed to obtain full information regarding the health and care needs of a recently admitted service user. Generally, the range of needs presented by service users is being appropriately met. EVIDENCE: Standards 1 to 4 assessed. Standard 5 met at the last inspection. The registered provider confirmed that all service users have now been issued with a revised copy of the home’s service users’ guide. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 10 The home has developed a contract format that is more user friendly; this is being written in an appropriate format/language. However, two recently admitted service users have not yet been provided with a contract. Since the last inspection there have been two new admissions to the home. The inspector examined the service users’ files and found no evidence of any contract having been drawn up between the home and the service user. This is an issue that has been identified from a previous inspection and for which a requirement applies; this must be addressed as a priority. Both service users must be provided with a contract and a contract put in place for all future admissions. 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 found that for one service user, no care management assessment or care plan had been obtained from the referring agency, and no pre-admission assessment had been completed by the home. For the other admission, a transfer from another home, assessments and a care plan had been received. Risk assessments were completed by the home and care plans drawn up for both admissions. A requirement applies. Review notes indicate that both service users have settled at the home and are now permanently resident. Care plans are being reviewed on a monthly basis. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Risk assessments, to safeguard service users, are being completed and reviewed with service users. Training in carrying out risk assessments has been provided for most, but not all, of the home’s staff. While service users are being protected by appropriate policy and procedures for medication, their protection also requires that accredited medication training is extended to all remaining staff who have not so far undertaken this. Service users who wish to self-administer their own medication are now being risk assessed. EVIDENCE: Standards 7, 8 and 9 assessed. Standards 10 and 11 met at the last inspection. Care plans are compiled on the basis of the initial assessment prior to admission, on admission and during residency. Two service users recently admitted to the home are evidenced to have had care plans put in place. These Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 12 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. Care plans and risk assessments are now being reviewed and recorded on a monthly basis. Following a requirement from the previous inspection, 8 staff have received relevant training in carrying out risk assessments. This training must be extended to all remaining care staff, hence the requirement still applies. A requirement from the last inspection for all staff who administer medication to complete accredited medication training has been progressed, with 10 staff having completed this training; 4 staff have still to do so, hence the requirement still applies. A risk assessment for two service users who wish to self-administer their own medication (one of whom takes insulin), has been completed in accordance with a requirement from the last inspection. The risk assessments need, however, to be signed and dated by the person completing the risk assessment, and by the service user and his/her nearest relative. A requirement applies. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: All standards met at the lat inspection. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 14 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): 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 home’s policies, procedures and practice indicate that, generally, service users are being protected from abuse. To ensure safety, however, the home’s procedure for reporting allegations of abuse must be amended to include the Local Authority’s guidance. EVIDENCE: Standards 16 and 18 assessed. Standard 17 met at the last inspection. The home has a policy and complaints procedure. The complaints procedure is clear and simple and includes the stages and time scales for complaints to be managed. The procedure has been amended so as to state that a complaint can be referred to the CSCI at any time. There has been one recent complaint which the inspector discussed with Mrs Balachandrun. The inspector spoke in private with the service user, and discussed with Mrs Balachandrun the appropriate actions that are required to address the concerns expressed. A requirement applies in respect of Standards 24 and 25. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 15 There have not been any adult protection concerns since the last inspection. The home has now obtained a copy of the Local Authority’s Procedure on the Protection of Vulnerable Adults. However, there is a requirement to be met, for the home’s internal adult protection procedures to be amended and updated, so as to include the Local Authority’s guidance. The home has a Whistle Blowing Policy in place for staff to reference should the need arise. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 16 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): Service users have access to safe and comfortable communal facilities. Service users expressed presented as settled and satisfied with their environment. Generally, service users’ bedrooms presented as safe, comfortable and pleasantly decorated, and suited to their occupants’ individual needs. However, new carpeting is required in one bedroom as the existing one has become unhygienic. Generally, the home presents as clean, pleasant and hygienic. Infection control training has recently been undertaken by most, but not all, of the home’s staff. EVIDENCE: Standards 20, 24 and 26 assessed. Standards 19, 21 to 23, and 25 met at the last inspection. The inspector spoke to a number of service users. Positive views were expressed regarding the ‘homely’ and pleasant home environment, with Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 17 residents indicating that they were happy with the communal facilities provided. The inspector completed a tour of the premises during which he visited the room of a service user where concerns had been expressed regarding hygiene heating and ventilation. The inspector was concerned by the strong smells in the room associated with urinary incontinence and is making it a requirement for the existing carpeting to be regularly shampooed on a 4-weekly basis. The registered provider advised that the existing carpeting is soon to be replaced with a new carpet, this being included in the requirement. The inspector discussed the level of heating in the room, which had been referred to by the complainant, and the apparent lack of ventilation. The service user indicated, however, that the temperature felt right for her and did not indicate any wish for this to be adjusted to a lower temperature. A requirement from the last inspection, for an armchair to be replaced in Room 11, has still to be met. A wall-mounted lamp over the bed has, however, been installed. Generally, the home presented as being clean and hygienic. The kitchen was inspected and presented as clean and maintained in accordance with food and hygiene standards. An infection control policy is in place. A requirement for staff to receive infection control training has still to be fully met (see standard 38), 10 out of 14 staff now having completed this training. All COSHH items were observed to be securely stored in locked cupboards. The Home was inspected by the Environmental Health inspector on 8 February 2005. A copy of the inspection report was viewed by the inspector. Two recommendations from the report have been acted upon. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 18 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): 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. Whilst, generally, service users are being safeguarded by appropriate recruitment policy and procedures, a CRB (Criminal Records Bureau) certificate has not been obtained for one staff appointment. While the protection of service users has been provisionally assured with the completion of a POVA (Protection of Vulnerable Adults) First check, and the provider’s assurance of compliance with CSCI guidelines, relating to the staff member’s supervision and contact with service users, prior notification must be made to the CSCI (and agreement given) regarding any future staff appointment where a CRB certificate has not been received. EVIDENCE: Standards 27, 28 and 29 assessed. Standard 30 met at the last inspection. The inspector checked the staff rota. A minimum of two staff are provided at any time, 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. At the time of inspection there were three staff on duty. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 19 The inspector examined the staff files of two new staff members and found that one CRB (Criminal Records Bureau) check was not in place. A POVA First check has, however, been completed, and an assurance given by the provider that until such time as the CRB certificate has been received there will be no one-to-one contact with service users, and that the staff member will be supervised at all times by an experienced (named) staff member. The inspector informed the registered provider that this must be put in writing to the CSCI, for this and any future staff appointment where an up-to-date and valid CRB check has not yet been received. All other identity and employment checks were found to have been satisfactorily completed, bar one. These included the full name, address, date of birth, copies of Birth Certificates and passports (if any), two written references from previous employers, and the dates when employment commenced. A photograph of one recently recruited staff member did not appear on the file and must be put in place; a requirement applies. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Service users’ views indicate that the home is being run in their best interests. Staff are now being provided with regular supervision, and a system of staff appraisal is being developed. However, a new supervision format needs to be developed to fully evidence issues discussed. The home needs to evidence that it is annually reviewing its policies and procedures. These must be signed and dated, and a policies and procedures checklist maintained. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 21 Generally, the inspector is satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected; most, but not yet, all staff, have undertaken infection control training. EVIDENCE: Standards 31 to 33, and 36 to 38 assessed. Standards 34 and 35 met at the last inspection. 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 is concerned that a registered manager has not yet been appointed. A requirement made at the last inspection, for the registered persons to appoint a qualified manager to manage the home has not been met. While Mrs Balachandran does not have a background in residential care, she stated that she is hoping to complete studies leading to the RMA (Registered Manager’s Award) and NVQ Level 4 by the end of April 2006, and to then apply to become the Home’s registered manager. The inspector is, however, concerned at the delay in appointing a registered manager, and is setting a final extension deadline for meeting this unmet requirement; if not met, this is likely to result in enforcement action being taken. The management approach of the registered providers is observed to be one that creates a positive and inclusive atmosphere. The inspector spoke to a number of service users in the residents’ lounge and evidenced a high level of satisfaction with the home. Service users generally expressed positive views regarding the proprietors and their management of the home. Both staff and service users are, wherever possible, encouraged to participate in the day-to-day operation of the home and to express their views through service user and staff meetings. The inspector observed that staff interacted well with service users and presented as being caring and supportive. Staff spoken to felt that they were being well supported by management in their daily roles. There is an outstanding requirement for the home to develop an effective quality assurance system. This should ensure that the home is meeting its aims, objectives and statement of purpose. Since the last inspection the home Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 22 has been developing its quality assurance processes. A questionnaire has been devised and completed with the home’s service users, and questionnaires have been developed for the relatives/friends of service users, and one for visiting care managers and other professionals. The home is yet to carry out an annual audit, the results of which should be sent to the CSCI, local office. In addition the home has still to put in place an annual development plan. The inspector sampled some staff files and found that staff supervision is still now 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. There is, however, a need for the home to develop a structured format for recording supervision. Supervision needs to cover all aspects of practice, philosophy of care in the home and career development needs of the staff as a minimum. The inspector recommends that the format of supervision is addressed as not all of these areas are being covered. Mrs Balachandrun informed the inspector that she and her deputy manager, and senior care officer, are to undertake supervision training with SSTAR (Safe Staff Training and Recruitment). There is an unmet requirement from the last inspection 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; this needs, however, to be evidenced. All policies and procedures must, therefore, be signed and dated to indicate the date of their adoption and each review, and details of these dates included on a policies and procedures checklist. A requirement from ther last inspection, for all staff to receive infection control training, has been partly met. 10 of the 14 staff completed this training on 12/9/05, and Mrs Balachandrun advised that the remaining 4 staff are due to undertake this in February 2006. Certificates evidencing the training completed were seen by the inspector. All staff have received approved manual handling and food hygiene training, and five staff have attended a one day first aid course. 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.V276179.R01.S.doc Version 5.1 Page 23 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 3 2 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 x 3 2 2 x 2 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 1 x x 1 3 2 Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 24 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 OP2 Regulation 5(1)(b)(c) Sch4, No8 Requirement The registered person must ensure that the terms and conditions between the home and service user is drawn up for two recent admissions, and for all future admissions. These must be held on file alongside the local authority three-way contracts (2.2). The home’s contract must be written in a user-friendly format, state the number of the room to be occupied, and be signed by the service user or his representative. The registered person must ensure that full and comprehensive information, regarding service users health and care needs, are obtained from the referring agency prior to admission. This information must be obtained for a recent admission which followed referral from social services. The registered person must ensure that the home completes a comprehensive pre-admission assessment for all new DS0000043469.V276179.R01.S.doc Timescale for action 31/01/06 2 OP3 14(1)(a) & (b) 31/01/06 3 OP3 14(1)(a) & (b) 31/01/06 Rosina Lodge Version 5.1 Page 25 4 OP9 13(4)c, 18(1)c 13(2) 5 OP9 6 OP9 13(2) 7 OP18 13(6) 8 OP24 16(2)c 9 OP24 OP25 13(4)(c), 23(2)(d) 10 OP29 19(1)(b) Sch2 11 OP29 19(1)(b) Sch2,No7 admissions. Training in carrying out risk assessments is required for all those staff who have not yet completed this. Risk assessments completed with two service users who administer their own medication must be signed and dated by the person completing the assessment, the service user and the nearest relative. The registered person must ensure that all those care staff who have not done so, complete accredited medication training. The home’s internal adult protection procedures must be amended and updated to include the Local Authoritys Vulnerable Adults guidance. One worn-looking armchair in Room 11 must be replaced. A small bedside table and table lamp are required for Room 16. 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. Existing carpeting must be replaced with new carpeting. The registered person must ensure that all identity and employment checks, including a recent photograph, are completed prior to any new staff member commencing employment at the home. The registered person must obtain an up-to-date CRB certificate for a staff member who has recently commenced employment at the home. The registered person must ensure that, where an up-todate CRB certificate has not been DS0000043469.V276179.R01.S.doc 31/03/06 31/01/06 31/03/06 31/03/06 31/03/06 31/01/06 31/01/06 31/01/06 Rosina Lodge Version 5.1 Page 26 12 OP31 9(1) (2) & 10(1) 13 OP33 24(1)(2)( 3) 14 OP36 12(1) received, a POVA First check is completed, and a written notification sent to the CSCI. This must provide an assurance that there will be no one-to-one contact with any service user, or assistance given with any personal care, and that the staff member will be supervised at all times by an experienced (named) staff member(s). This arrangement is subject to the inspector’s agreement (given on this occasion) and must be put in writing to the CSCI prior to any future staff appointment (where an upto-date and valid CRB check has not been received). The registered persons must 31/03/06 appoint a qualified manager to manage the home without further delay; or, if a manager is employed without NVQ at Level 4 in care, they must commit to completing the Course (31.1, 2, 4 5). Any registered manager must have at least two years experience in a senior management capacity in the managing of a relevant care setting within the past five years. Final extension of timescale which, if not met, will result in enforcement action being taken. The registered persons must 31/03/06 ensure a quality audit system, including an annual development plan is in place to assess whether the aims and objectives of the home have been met. Policies and procedures adopted 31/03/06 by the home must be reviewed by the registered persons. They must be signed and dated at the point of adoption, and reviewed every 12 months. These dates DS0000043469.V276179.R01.S.doc Version 5.1 Page 27 Rosina Lodge 15 OP38 13(3) must be recorded on a Policies and Procedures checklist, and be signed by the responsible person. The registered person must ensure that those staff who have not done so, complete infection control training (standard 38.2). 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP36 Good Practice Recommendations Supervision needs to cover all aspects of practice, philosophy of care in the home and career development needs of the staff as a minimum. The inspector recommends that the format of supervision is developed so as to ensure that all of these areas are being covered. Rosina Lodge DS0000043469.V276179.R01.S.doc Version 5.1 Page 28 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.V276179.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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