Inspection on 12/11/09 for Rosebery House

This is the latest available inspection report for this service, carried out on 12th November 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosebery House 01/05/08

Rosebery House 03/05/07

Rosebery House 10/04/06

Rosebery House 20/02/06

Rosebery House 14/12/05

Rosebery House 21/06/05

Rosebery House 30/11/04

Rosebery House 18/05/04

Rosebery House 02/12/03

Rosebery House 10/06/03

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Rosebery House 2 Rosebery Avenue Eastbourne East Sussex BN22 9QA Lead Inspector Debbie Calveley Key Unannounced Inspection 12th November 2009 09:00 DS0000021246.V378480.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Rosebery House DS0000021246.V378480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosebery House Address 2 Rosebery Avenue Eastbourne East Sussex BN22 9QA 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) 01323 501026 01323 511124 hilenshah@aol.com Spemple Ltd Ms Clare Sobhanieh Care Home 30 Category(ies) of Dementia (0) registration, with number of places Rosebery House DS0000021246.V378480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE). The maximum number of service users to be accommodated is 30. Date of last inspection 27th October 2008 Brief Description of the Service: Rosebery House is a large, detached property situated in a quiet residential area of Hampden Park in Eastbourne. Local shops and amenities are a short walk away. The home is registered to provide residential care to thirty older people with dementia. Single bedroom accommodation is provided on two floors. Level access is provided by way of a passenger lift. All bedrooms are equipped with a call bell and four have ensuite facilities. Communal areas consist of a large lounge, dining room and quiet seating area. A large, rear garden provides a safe and pleasant area for residents to walk in and relax. Assisted bathrooms and toilets are located on both floors of the home. The fees at Rosebery House are available on request and are dependant on the assessed needs of individual people. More detailed information about the services provided at Rosebery House can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are on display in the reception area of the home. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.2 Page 5 Rosebery House DS0000021246.V378480.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Rosebery House will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 5.5 hours on the 12 November 2009. There were twenty four residents living in the home on the day of which four were case tracked and spoken with. During the visit, eight other residents both male and female were also spoken with. A wide selection of staff were spoken with and included: Three carers, an ancillary worker, cook and registered manager, Ms Sobhanieh The purpose of the inspection was to inspect the key standards against the information received from the completed Annual Quality Assurance Assessment AQAA and the last key inspection. The inspection process also included viewing a range of documentation: the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Telephone contact was made with health and social care professionals during and following the visit. The information received verbally has been incorporated into this report. What the service does well: There is a detailed and informative Statement of Purpose and Service Users Guide that gives prospective residents and/or their representative the information required to enable them to make an informed choice about where they live. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.2 Page 7 The home is well maintained and homely and residents are enabled to live with their own possessions around them. The menus evidence a well thought out balanced diet with a varied choice of food in line with residents’ preferences. Quality assurance systems are in place which enables the service to monitor and improve their service and ensure that the home is run in the best interests of residents. There is an open-house policy which welcomes visitor’s at all reasonable times. Satisfactory arrangements are in place to safeguard resident’s finances. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The Comments received from residents and families regarding the care received included, ‘friendly and helpful’ The training for staff is good, and covers a wide variety of resident related conditions, which give the staff an understanding of the residents needs. What has improved since the last inspection? What they could do better: There are aspects of the care documentation that need to be developed to ensure that the staff have the necessary guidance to meet the individual needs of the residents. The staffing levels need to be reviewed regularly to ensure that there are appropriate numbers of staff on duty to protect and promote the residents health safety and well being. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 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 Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides prospective residents and relatives with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission. EVIDENCE: There is a comprehensive and informative Statement of Purpose and Service Users Guide in place that are written in plain English. Families spoken with confirmed that they had received a service user’s guide when their relative was admitted to the home. These documents give prospective residents and their representatives the information they need to make an informed choice about where to live and what services and facilities the home offer. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 11 It was confirmed whilst talking to visitors that the contract arrangements were clear and understood. There is a copy of the terms and conditions of residency included in the homes information documents A review of the care documentation confirmed that pre-admission assessments are completed by a competent person. The latest admissions to the home were identified and the records relating to the admission procedures followed were reviewed. This confirmed that pre admission assessments are completed and provide an adequate assessment of prospective residents care needs. Prospective residents are seen either in their home or hospital before admission and the input from relatives and other professionals is used whenever possible. As discussed this could be reflected in the assessment document. It was confirmed that the home confirms in writing that having regard to the assessment that the home can meet the assessed needs of the prospective resident. It recommended that the format of the letter is reviewed to fully meet its purpose. Ms Sobhanieh was knowledgeable regarding the people who live in the home and stated that staff receive training in order to meet the residents differing needs. Trial visits to the home can be arranged. It was confirmed that residents are invited to a trial period to ensure suitability of the home this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Intermediate care is not provided at Rosebery House Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provide a good framework for the delivery of care, which give clear guidance to care staff on all the needs of the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. Medication practices in the home promote and protect the health needs of residents and the privacy and dignity of residents are promoted. EVIDENCE: The care documentation pertaining to four residents was reviewed in depth as part of the inspection process. The format of the care plans used in the home is comprehensive and detailed and one relative spoken with confirmed that they had been involved in planning their relatives care. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 13 The residents were found in the main to have care plans specific to their needs and evidence regular review since the last key inspection. Risk assessments for health needs are included in the care planning format used by the home and risk assessments were found to be completed and followed through with an appropriate plan of action when identified as required. The homes documentation in respect of their health needs ensure that residents receive the care and support they need to protect and promote their health. Areas that need developing were discussed in full and include aggression guidelines and short term care plans for short term illnesses and injuries. The shortfalls were acknowledged and will be addressed. Residents are registered with a GP from local surgeries and all residents have access to health professionals as and when required. A district nurse was visiting the home and the comments about the home and staff included: ‘The staff have a good knowledge of the individual residents’ ‘Always polite and friendly’. The health needs of residents are adequately met with evidence of good multi disciplinary working taking place on a required basis. Residents spoken with were satisfied with the care provided at the home one saying that the home ‘Oh its lovely I am comfortable’ ‘Like the food’ ‘Pretty good’. There are policies and procedures in place for staff to refer to regarding the safe administration, storage, disposal and recording of medication. The medication administration charts were in the main competently completed. Some minor shortfalls were discussed and will be addressed. This includes resident’s photographs for identification purposes. The resident’s health needs are promoted and protected by the homes medication practices. The residents spoken with confirmed that they were treated with dignity and respect and that their right to privacy was respected. During the site visit residents were addressed by their preferred term and dressed appropriately in well-laundered clothing. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social activities and meals provide daily variation and interest for people living in the home. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: The lifestyle within the home is flexible and from direct observation residents were able to choose when they get up; have breakfast and where they spend their time. All the care plans viewed contained information regarding resident’s preferences in respect of their daily routines and include a night plan to guide the staff. Care plans evidence resident’s personal histories and social preferences and these could be linked more constructively to a formal activity programme. The activity co-ordinator has recently left and the home are currently advertising the post. In the mean time Ms Sobhanieh has stated that they have brought in an extra carer to provide afternoon activities. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 15 One comment received did mention that they felt there could be more interaction with residents. It was noted that there were no books or newspapers in the home and from spending time with certain residents this would enhance their life. It was observed during the inspection that the routines at the home are flexible; one resident said ‘I can go where I want’. One relative said ‘The residents are encouraged and supported to make decisions and this included choosing their clothes’. Residents are supported and facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the residents. Many of the residents have individualised their bedroom with items from home and two residents were able to confirm that they can bring in their own bits and pieces. The home has an advocacy policy in place and the information regarding this is available to all residents and/or their families. The mid day meal was observed and was seen to be organised and well managed. This ensures that those residents needing assistance were given time and able to have the assistance that they needed in an unrushed manner. The menu of the day is displayed in the communal areas of the home, the residents are also asked verbally on the day and they can ask for something different if they wish. Records are kept of the meal and of the quantity eaten by the care staff. Any variations to a diet or if a supplement is required is then relayed to the chef. There is a four weekly rotating menu that demonstrated a nutritious and well balanced diet. The meal seen was attractively presented and the soft/pureed option was also attractively presented. The chef serves the food in the dining area and so individual wishes are respected. The feedback concerning the food was positive and it was confirmed that a cooked breakfast is available daily. There was evidence of fresh fruit and vegetables in the home and all the staff have undertaken the food hygiene course. The kitchen was clean with records as required by the Environmental Health Agency in place. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a formal complaints system with evidence that residents feel that their views are listened to and acted upon. Staff receive training to protect residents from abuse. EVIDENCE: The home has a formal complaints policy and procedure and this is available in the service users guide and statement of purpose. The complaint log was viewed and evidenced that complaints are take seriously, investigated and responded to. The responses from the complainant were also seen. All staff are aware of their responsibilities regarding the protection of those in their care and have all received the appropriate training. Ms Sobhanieh was aware of the reporting protocols under the adult protection system and the procedures involved. Ms Sobhanieh was aware of the Deprivation of Liberty guidelines and staff are in the process of receiving appropriate training Robust recruitment processes protect their residents and promote their safety. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 17 Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Rosebery House provides a comfortable, clean and safe environment for those living in the home and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests EVIDENCE: Rosebery House is well maintained, comfortable and safe and meets its stated purpose and the aims and objectives of the home. There is a refurbishment and redecoration programme in place. The AQAA gave information of what has been accomplished and what they are proposing to do. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 19 Careful consideration has been given to introducing colour in to the décor which enables residents to find their way to bathrooms and their bedrooms, the staff have also personalised their bedroom doors with personal pictures so helping residents to be more independent. The gardens are accessible and pleasant for residents and visitors to the home. The home have a choice of various communal areas which are attractive and allow for different uses ensuring residents have choice where they spend their time. Residents were observed being able to wander safely around the communal areas of the home. The home has specialised equipment available throughout the home to promote health and encourage independence. In relation to fire safety, all records are current and in place to protect the safety of those living and visiting the home. All of the staff team attend regular fire safety training. It was confirmed that all staff receive training in infection control and that the policies and procedures are updated regularly. They are easily accessible to staff thus protecting those living and visiting the home from risk of cross infection. Good practice in respect of infection control measures by staff was observed during the inspection visit and there were gloves and aprons freely available in the home. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Robust recruitment procedures are in place to protect residents, and staff training ensures they are aware of their roles and are able to provide the support and care the resident’s need. However the staffing levels need to be reviewed regularly against the needs of the residents to guarantee their safety and well being at all times. EVIDENCE: From direct observation and from viewing the staffing rota it evidenced that there were appropriate numbers of trained and competent staff on duty during the day to care for the residents. However if one carer in the afternoon is taking on the responsibility of activities at this time, it could impact on the safety of the residents and this needs to be taken into consideration and reviewed. The staffing rota seen did not evidence the extra carer that was discussed during the visit. The staffing levels at night need to be reviewed daily against the dependency levels and the amount of residents that are wakeful and wandersome. It is acknowledged that there are alarms under mats that would alert staff when someone is on the move but the building is large and spread out which could impact on the well being of the residents. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 21 The staff turnover has been high over the past few months which has concerned relatives as it is unsettling for residents. However this is acknowledged and is being monitored by the senior staff of the home. A selection of staff recruitment files were viewed and demonstrated that there is a thorough and robust recruitment process in place to protect their residents The documentation in the files supported the information supplied in the AQAA that all staff receive a thorough induction to the home which includes shadowing senior staff on their first shifts in the home All new staff complete a trial period to ensure that the job is suitable for them Staff spoken with said that training opportunities are being offered Ms Sobhanieh has introduced a training matrix which enables the management team to track the training needs This ensures that all staff receive the training required to perform their job competently and therefore promoting the health and well being of the residents living in the home There is an induction programme in place and has been introduced for all staff Files seen confirmed this. The induction and foundation training is in line with the Skills for Care guidance New staff are required to complete an initial induction programme and undertake mandatory training including fire and health and safety. This leads into foundation training in preparation of National Vocational Qualification (NVQ) Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The overall management of this home is good with effective systems in place to protect residents and ensure their continued health and well being. EVIDENCE: There is now a competent and effective registered manager in post that has been pro active in maintaining the improvements seen at the last key inspection and meeting the requirements made. Ms Sobhanieh has experience in managing a care home and has both the management and care qualifications necessary. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 23 There are systems in place to monitor the quality in the home and include the use of questionnaires. It was confirmed that these are audited, reported on and responded to. There are relative meetings yearly and staff meetings which are minuted and form part of the quality assurance systems. The regulation 26 visits are performed monthly by a quality consultant and these were thorough and included action points to be completed. The home does not manage any monies for residents. The systems in place safeguard the resident’s financial interests. Evidence was seen of regular two monthly supervision sessions and all staff spoken with confirmed that they felt it beneficial. The AQAA confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies. The manual is available to all and clearly defined with regularly updated policies and procedures and best practice guidelines that ensure the health safety and welfare of the people using the service. Staff were able to discuss the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. The accident book was completed in full and strategies are put in to place for prevention of a recurrence. First aid boxes are located in the home and easily assessable when required. All staff have received the mandatory training necessary to promote and protect the safety and well being of the residents. The manager confirmed that all staff are appropriately supervised until they have received the necessary training. Good practice was observed throughout the inspection in respect of promoting the safety and well being of the residents. Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18 Requirement That the Registered Provider ensures that there are sufficient competent and trained staff on duty to meet the needs of the service users at all times. To ensure the health, safety and welfare needs of the service users. Timescale for action 20/01/10 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 Rosebery House DS0000021246.V378480.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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