Inspection on 07/07/05 for Rose Mount

This inspection was carried out on 7th July 2005.

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

Rose Mount 17/01/07

Rose Mount 15/12/05

Rose Mount 17/01/05

Rose Mount 26/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Rose Mount 138 Stourbridge Road Holly Hall Dudley West Midlands. DY1 2ER Lead Inspector Jean Edwards Announced 7 July 2005 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Rose Mount Address 138 Stourbridge Road Holly Hall Dudley West Midlands. DY1 2ER 01384 457855 01384 457855 nigeldhillon@blueyonder.co.uk Rosemount Residential Home Ltd. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr. Nigel Dhillon Care Home 3 Category(ies) of Learning Disability LD (3) registration, with number of places Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17/01/05 Brief Description of the Service: Rose Mount is a small private Residential Care Home, providing accommodation for up to three adults under the age of 65 years who have learning disabilities. The Home is situated on a busy main road, with easily accessible bus routes to a number of nearby towns and shopping centres, Merry Hill, Dudley, Wolverhampton, Brierley Hill, Stourbridge etc. There are numerous local amenities within walking distance from the Home, Post Office, library, church, health centre, parks and pubs. There is limited car parking, two cars at the frontage to the property, with limited on road parking nearby. The accommodation provided consists of three good size single bedrooms, one on the ground floor and two on the first floor. There is a lounge/dining area, toilets, and bathing facilities. The office is located in the cellar. There is a garden and patio to rear of the Home, accessible to Residents. The Registered Manager and Joint Proprietors provide staffing. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection visit took place over a weekday morning. The purpose of this visit is to assess progress towards meeting the national minimum standards for younger adults and towards required improvements identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: a formal discussion with the registered manager who is also joint owner. There was brief tour of the premises. Only one of the two residents accommodated was at home during the inspection process. He was happy to join in the inspection providing information about his and his friend’s experiences during discussions. Although survey cards were sent to a range of people by the CSCI, none have been returned at the time of writing this report. Since the last inspection in January 2005 the manager has had discussions with the Social Services Department about the future direction of Rosemount, looking at other possibilities for the people to continue living at the home, maybe as tenants, with supported living arrangements. What the service does well: The two residents are encouraged by the manager / owners to treat Rosemount as their own home and to be as independent as they wish. During the inspection the person at home used the kitchen to make his own breakfast and drinks and washed his dishes without any prompting. Residents are able to make their own choices and are able to express their own wishes and pursue their own individual lifestyle. One person is able to work in full time employment at a local foundry, the other person does voluntary work for the health service and also uses a local social services day centre for opportunities for socialising. The home celebrates important events in residents’ lives. One resident had a recent birthday, with celebrations to mark the event. The manager and the two residents regularly visit the cinema at Merry Hill, though each person also has separate hobbies and interests, which they pursue independently. One resident likes to play pool and is the unbeaten champion of the social services day care service league, beating all comers, even the day centre staff. The premises are maintained to high standards and the home is clean, tidy and homely. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed at this visit. The home has not accepted any new admissions for several years. EVIDENCE: There are two male residents at Rosemount, who have lived at the home for more than ten years. They pursue fully independent lifestyles, one person works in full time employment, the other does part time voluntary work. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9,10 There is a clear and consistent care planning system in place to adequately provide information to satisfactorily meet residents’ needs. EVIDENCE: Each resident has a comprehensive care plan in place, and they are signed by the residents to indicate their agreement. During discussions with one of the residents whose care was tracked during this visit confirmed that there is an active involvement in developing and implementing their care plans. Elements of care plans are reviewed on a six monthly basis, with evidence that residents, relatives (where the person consents), advocates and other professionals have been invited to participate in this process. One person has been reassessed as no longer needing residential care. Further reviews and discussions about future support for both people are due to take place later this month. The two residents at Rosemount are very able and have good numeric and literacy skills, they both manage their own finances, without any need for help Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 11 from the registered manager / joint proprietor. Assistance is available to them should the need arise regarding their rights to benefits. The registered manager has considered all risks associated with the residents and developed a number of risk assessments with them. However he has not yet been able to undertake the approved / accredited risk management training planned for earlier this year because the course was cancelled due to low numbers. The training is now rescheduled for 7 September 2005, through the West Midland Care Homes Association. Following the training all risk assessments need to be reviewed. There are specific areas of risk identified by the Senior Environmental Health Officer at the Health & Safety inspection of the home on 10 March 2005. Residents are aware that information relating to them is held securely by the home and treated in confidence. The registered manager has now produced documentary evidence that the residents are aware of their rights to access their own information held by the home. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,17 Links with the community are good, these support and enrich residents social, work and educational opportunities. The meals at Rosemount are planned and prepared by residents, providing both choice and variety. EVIDENCE: One of the residents was at home for a time during this inspection visit, the other person was at work. The person at home was seen making his own drinks and toast for breakfast. Both residents take responsibility for house hold tasks with some support from the registered manager. They have devised their own cleaning rota, for a fair division of labour. There are care plans in place relating to daily living skills. During a conversation the person commented that manager is very helpful but also very good about prompting him to do those tasks that he could, to preserve and improve his level of independence. During discussions with the resident at home, he spoke enthusiastically about his volunteer work at Dove House, a local mental health facility. He is Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 13 particularly pleased about a recent ‘Elvis tribute’ entertainment there, which went very well. He talked about the surprise visit to the event by his sister, which was arranged for him by the staff from Woodside day centre, where he still attends on a part time basis and at some time at weekends. He is particularly impressed with the laptop computers at Woodside, which he has used to write a review of the Elvis tribute event. The other resident continues to work in full time employment at a local foundry and continues to have a good social network of friends. There are no restrictions relating to visiting times at Rosemount and friends and families are welcomed, and are offered refreshments or meals. Information about residents’ family/friends relationships and links are documented in each person’s plans. One person has chosen not to have his family involved in his formal reviews and he has made a statement that no information is to be shared with them relating to his care, however he does maintain some contact with his brother, mainly at Christmas and he also has some contact with his sister. Both people are able to access facilities in the community. For example they go shopping, use the library and go to the cinema. They generally plan outings and travel independently, though they both go with the manager to the Merry Hill cinema on a regular basis and have a weekly wander around the shops at Merry Hill. The home now has a pet dog, a bull mastiff, Spike (belonging to the manager), beloved by one resident in particular. This person enjoys nature walks and buys nature books most weeks. The annual holiday last year was taken at the Isle of Wight, however no plans for this year’s holiday have been finalised to date. There is no set daily or weekly menu, though a record of meals is kept retrospectively. Residents are involved in the food shopping, preparing and cooking; and make meal preferences on a daily basis. The Manager and residents go food shopping weekly to either Asda or Aldi. Both people prefer traditional plain food, rather than spicy foods or elaborate meals. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Personal support in this home is offered in such a way as to promote and protect residents’ privacy, dignity and independence. The health needs of residents are well met with good evidence of multi disciplinary working taking place on a regular basis. There are policies / procedures in place for the administration of medication, however the current residents have no need for any medication to be administered by the home. EVIDENCE: Both residents are fully mobile and have complete and independent control over all aspects of their personal care needs. One person occasionally requires verbal ‘prompts’ from the registered manager / joint proprietor to remind him to maintain good standards of personal grooming. This is documented in his care plan. Both residents bathe daily. It is evident that each person chooses when to rise and retire, within the constraints of work and volunteer / day care attendance commitments. One person has to rise early to be out of the house and at work for 8.00am each day, except for weekends. There is documented evidence that both residents have an annual general check up with their own GP. Last health review was 19 November 2004. There is a health appointment index to track all health related visits, on each person’s case file, which is good practice. Discussions take place to ensure that Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 15 residents understand the need to regularly check themselves for any abnormal / unusual changes in their bodies. Recently one person has been seen by his GP regarding a lump, which has been diagnosed as ‘fatty tissue’ and no treatment is required. The residents usually attend the GP surgery unattended, though the manager is available if required. The person who smokes has made his own decision to try to give up, with support from his GP and Action Heart. He has prescribed nicotine patches. Both residents have regular dental checks, last appointment was 10 June 2005; and optical checks six monthly, next appointments are end of July 2005. No other health services are required at present. The situation relating to medication remains unchanged with neither of the two residents requiring any prescribed medication (other than the nicotine patches – kept by the resident). It has been agreed that should the need arise for any other medicines, both residents would be capable of administering their own medication. One person sometimes purchases Paracetamol for headaches and other homely remedies for his own use, as the need arises. The Manager has recorded this decision in his individual plan, with his consent. However the previous requirement to devise and implement a risk assessment with the service user for the self-administration of his own purchases, remains outstanding. The Manager has policies; procedures and a risk management framework relating the medication in care homes, in accordance with guidance issued in June 2003, by the Royal Pharmaceutical Society of Great Britain. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has a satisfactory complaints system with evidence that residents feel that their views are listened to and acted upon. There are policies, procedures, guidance in place in order to provide residents with safeguards from abuse. EVIDENCE: There have been no complaints recorded in the home’s complaints log since the last inspection visit in January 2005. The resident spoken to stated that he and his friend felt that they could voice any concerns either directly with the manager or staff at the social services department. The registered manager / joint proprietor has policies, procedures and guidance relating to the protection of vulnerable adults. There are no staff on an employed or voluntary status working at Rosemount. The staffing hours required continue to be provided by the registered manager and joint proprietors. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26,30 The manager has a good understanding of the areas where the home needs to improve and proactive planning is now in place indicating how this improvement is going to be resourced and managed. The standard of the décor within this home is generally good with evidence of improvement through maintenance and future planning. The home presents as a homely and comfortable environment for residents. EVIDENCE: Rosemount provides accommodation for up to three adults with learning disabilities. A brief tour of the premises demonstrated that the house is clean, homely and comfortable. The semi-detached house blends well with the local community and offers good access to local amenities. The fixtures, fittings and furnishings are good quality and domestic in character. The property is generally well maintained. The previous requirement to conduct a documented audit of the premises to identify maintenance and renewal required, from which a prioritised planned programme must be devised, is partly met with a record of replacement redecoration completed, the record of proactive planning remains outstanding. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 18 Each resident has an attractively decorated bedroom. There is ample evidence that they can personalise their rooms according to their individual preferences. The person consulted confirmed that he is able to make choices about both his personal space and the communal living accommodation. There are completed inventories of residents’ personal possessions, including furniture brought into the home on each person’s file. One person has written his own inventory. Both residents have lockable space and continue to hold keys to their bedrooms and the front door to the house. There is a high standard of cleanliness throughout the home, with everyone involved in domestic tasks. The manager has obtained infection control guidelines from Dudley Public Health / Infection Control and has devised policies and procedures to ensure that should the need arise everyone follows appropriate infection control measures. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35 The two residents are currently well supported by the registered manager / joint proprietor, with assistance from the other joint proprietors. No other staff are currently employed at this small home. EVIDENCE: Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 20 The two residents living at this home demonstrate a high level of independence. Living an independent lifestyle, requiring very minimal support. One person has been reassessed as no longer needing residential care by Dudley Social Services. The other person is due to be reassessed in the near future. The is staffed by the Registered Manager and Joint Proprietor, providing cover for the home as follows; 06.45- 10.00 am and 16.00- 20.00 Monday to Friday by the Registered Manager. 10.00 – 13.00 and 17.00 – 21.00 Weekends by Registered Manage and the Joint Proprietor. It is stated that the staffing arrangements are varied at times to meet the needs of the service users, and the hours are recorded retrospectively. The Registered Manager continues to make progress to meet the previous requirement to undertake necessary training and provide a training plan. This mainly relates to his own training and evidence of planned training has been made available. For example he plans to undertake food hygiene refresher training in August 2005. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39,41,42,43 The systems for resident consultation at Rosemount are good with some evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: The Registered Manager has a number of years of experience in the management of relevant care settings and has the Diploma in Social Work (Dip.SW), obtained in 1995. He is considering options to undertake training to obtain the Registered Manager’s Award (RMA), though this is dependent on the future direction of this care home. The home has yet to implement a comprehensive quality assurance system and must meet previous requirements to provide the CSCI with evidence of its annual development plan and formal systems of consultations and regular surveys of residents’ views. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 22 There is some evidence that the residents, who spend time on their own at the premises, have received fire safety instruction and fire drills since the last inspection visit. However it is strongly recommended that records of fire safety talks with residents are expanded to include the detail of topics discussed and instruction given, together with their signatures. A sample of fire safety and maintenance service records were examined, these were generally satisfactory, with only minor improvements required. A full health & safety inspection was conducted by a senior environmental officer from Dudley MBC Directorate of the Urban Environment on 10 March 2005. 12 legal requirements and 2 good practice recommendations were issued. Although it is acknowledged that there are areas of dispute, notably about gas safety, a detailed response / action plan must be copied to the CSCI Office, Halesowen. There have been no accidents involving residents or anyone else since the last inspection visit in January 2005. Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Rose Mount Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 2 E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 42 Regulation 13(4) Requirement To ensure that all areas of risk associated with individual service users are clearly documented, such as moving and handling, challenging behaviours, falls, personal safety within the Home’s environment and on any activities where the Home has a duty of care. (Timescale of 31/07/05 not met) To ensure that documented risk assessments and risk management strategies relating to the service users and the environment are reviewed, expanded and implemented following training. (Timescale of 31/07/05 not met) To provide accredited risk management training for any persons involved in undertaking risk assessments or engage the services of a ‘competent’ person to provide documented risk assessments, with control measures and risk management strategies. (Timescale of 31/07/05 not) To devise and implement a risk assessment for any homely Timescale for action 30/09/05 2. 9 42 13(4) 30/09/05 3. 9 13(2) 31/07/05 Page 25 Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 20 4. 24 23(2)(b) 5. 33 39 18(1) 24 6. 39 24 7. 39 24 remedies purchased by the service user who administers his own purchases, with his consent (Timescale of 31/05/05 not fully met) To conduct a documented audit of the premises to identify maintenance and renewal required, from which a prioritised planned programme must be devised. (Timescale of 31/05/05 not fully met) To ensure that meetings are held between the Manager and Proprietors and are formalised, minuted and held a minimum six times each year. (Timescale of 31/05/05 not met) To progress the planned development of the service users surveys, as required by standard 39; and include the results in the reviewed service user guide (Timescale of 31/05/05 not met) To devise and forward a copy of the annual development plan to the CSCI Satellite Office. (Timescale of 31/05/05 not met) To review and expand the policy relating to risk assessment and risk management following the Manager’s planned training on 06. 06.04 (Timescale of 31/05/05 not met) To forward the annual service certificate for the fire extinguishers to the CSCI Satellite office (Timescale of 28/02/05 not fully met) To submit a documented response and action plan to the CSCI regarding all issues identified in the Health & Safety report from Dudley MBC Directorate of the Urban Environment (Environmental Services) dated 10 March 2005 31/08/05 31/08/05 31/08/05 31/08/05 8. 42 13(4) 30/09/05 9. 42 23(4)(c) 31/07/05 10. 42 16(2)(j) 23(5) 31/08/05 Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 26 11. 42 13(4) 23(2) The registered person must ensure that there is a supply of blue plasters in the kitchen at all times The badly scorched electric kettle in the kitchen must be replaced / returned to the store as defective To produce a business and financial plan for the Home, with a copy forwarded to the CSCI, for consideration. (Timescale of 31/05/05 not met) 31/07/05 12. 43 25 31/08/05 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 42 Good Practice Recommendations That records of fire safety talks with residents are expanded to include the detail of topics discussed and instruction given, together with their signatures Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA 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 Rose Mount E55 S25002 Rose Mount V228161 070705 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!