Inspection on 02/08/06 for Rosemary Residential Care Home

This inspection was carried out on 2nd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosemary Residential Care Home 29/08/08

Rosemary Residential Care Home 11/09/07

Rosemary Residential Care Home 03/03/06

Rosemary Residential Care Home 29/06/05

Rosemary Residential Care Home 11/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Rosemary Residential Care Home Rosemary Residential Care Home 2 Guinea Lane Fishponds Bristol BS16 2HB Lead Inspector Sandra Jones Key Unannounced Inspection 2 & 22nd August 2006 09:30 nd Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 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 Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemary Residential Care Home Address Rosemary Residential Care Home 2 Guinea Lane Fishponds Bristol BS16 2HB 0117 9584190 0117 9020515 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) Mrs Regina Odeh Mrs Regina Odeh Care Home 10 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (8), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (1) Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 8 persons with mental disorder aged 19 - 64 years May accommodate up to 1 person with a learning disability aged 50 years and over May accommodate up to 1 person with mental disorder aged 65 years and over 3rd March 2006 Date of last inspection Brief Description of the Service: Rosemary is situated off Fishponds Road close to shops, places of worship and parks. Originally, the property was two domestic dwellings, converted to provide accommodation to ten people with mental health care needs. The home blends well with its local environment. It is operated by Mrs R. Odeh and registered to accommodate nine adults and one person over 65 years. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key visit was conducted unannounced over two days in August 2006 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the residents, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from residents, staff and visitors to the home. What the service does well: What has improved since the last inspection? What they could do better: Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 6 Five requirements are outstanding from the last inspection and urgent action must be taken to meet these requirements. Failure to comply may lead to enforcement action. The service provider must develop the care planning process to adopt a person centred approach to meeting needs. In terms of meeting resident’s mental health care needs, care plans must incorporate triggers of deterioration along with the actions to be taken. Where residents are subject to section under the Mental Health Act, care plans must be specific about the section and implications for the home. Reactive strategies must be developed for residents that misuse drugs and alcohol to ensure staff are guided to handle these situations. Complaints and Adult Protection policies and procedures must be developed to ensure that the people for whom it is indented can understand them. Additionally, procedures must be kept under review to ensure they meet good practice guidelines. Recruitment procedures must be improved, including the prompt obtaining of criminal records checks, so that it protects vulnerable adults Fire safety checks and practices must be conducted at the stipulated frequencies to promote the safety of the residents and staff at the home. 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. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 There is a clear procedure for admission at the home. EVIDENCE: An Admission and Emergency procedure is in place and incorporates the accommodation that can be offered under the Mental Health Act. Within the Statement of Purpose the admission criteria lists the specific statuses under the Mental Health Act that can be accommodated at the home. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Home’s care plans must be more specific about meeting assessed needs in a person centred approach. Residents must sign their care plans to evidence their awareness and summaries must be more detailed about the progress of the care plan. Triggers of a deteriorating mental health and the actions to be taken must be incorporated into the care plans with any restrictions imposed. Reactive strategies must be developed for residents that misuse drugs and alcohol and include restrictions imposed. Action plans must therefore be specific to ensure staff are guided to manage these situations. Risk assessments must be reviewed to ensure action plans are appropriate to the level of risk identified. EVIDENCE: Individual Care Programme Approach (ICPA) meetings are organised annually, with the psychiatrist, resident, care manager and other agencies present. Residents were allocated a care coordinator, which organises ICPA. From the meetings an enhanced care plan is sent to the home. While the home develops care plans, action plans must be amended following the review meetings. Home’s care plans must be specific about meetings residents needs, and must incorporate the person’s likes, dislikes and preferred routines. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 10 Monthly summaries are complied and briefly state the effectiveness of the care plan. In terms of the resident’s mental health care needs, care plans must describe the triggers of deterioration and the actions to be taken by the members of staff. For residents under section care plans must describe the actions to be taken for breeches of conditions including restrictions imposed. It is evident from the case records that a number of residents have restriction orders imposed. Care plans must be clear about the restrictions imposed, with the actions to be taken for breeches of restriction orders. Additionally there are a significant number of residents that abuse drugs and alcohol, reactive strategies must be specific about the staff’s actions whenever residents use illegal substances and alcohol. Members of staff must be sufficiently guided to manage these situations. Running reports are compiled by the staff on duty and describe the outcome of visits, observations of the residents and general information about their day. From the reports is evident that residents make decisions about their day. For example, times to rise, times to retire and daily activities. Members of staff stated that they have access to care plans and make entries in residents daily reports. Residents consulted confirmed that they participate in ICPA meetings. Two residents are restricted from entering local shops and pubs because of inappropriate behaviour. Knives are locked away at night to prevent residents from using utensils inappropriately. It was understood from the service provider that the residents currently accommodated are able to make their own decisions. Risk assessments are in place for activities that may involve an element of risk. However, the assessments require reviewing to ensure that they remain appropriate to the level of risks. The home maintains an accident book for staff and residents. There were no recorded accidents since the last inspection. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,15,16 &17 The service provider must introduce systems that increase residents opportunities to take part in fulfilling activities. Residents can access the local community without staff support. Steps are taken at the home for residents to strength links with family and friends. Residents state that staff respect their rights as individuals. Meals prepared at the home are varied and wholesome. EVIDENCE: The service provider reported that discussions with residents about their education and occupation take place informally. A formal structure for discussing aspiration and goals is not currently in place. Care plans must incorporate resident’s wishes about education and occupation. It was further stated that during quiet periods staff are expected to sped time with residents. Assisting residents to maintain bedrooms tidy, accompany residents to visit GP and 1:1 are the roles undertaken by the staff with residents. One person currently attends day care and one is employed and attending college. A social worker visiting the home, during the inspection, agreed to Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 12 give feedback about the levels of care observed. The social worker was stated that impressed in the way two residents placed by her have been cared for at the home. The service provider reported that the residents are able to leave the home without staff support. Residents are provided with keys to the home and their bedroom, to increase their levels of independence. Residents are informed about events and if requested staff will accompany residents. Residents giving feedback during the inspection confirmed that they were able to leave the home without staff support. The Statement of Purpose describes the arrangements for visitors at the home. It states that visitors are welcome at all convenient times and commits to offering all necessary facilities for advocates. There is a visitor’s book at the home and visitors record the nature and date of their visit. Four residents maintain contact with family and friends. The rules and expectations of both parties are not currently described in the Statement of Purpose. The expectations for respecting residents rights are set out in the home’s Privacy and Dignity policy. Within the procedure, the expectations that staff respect the individual are specified. Residents comments indicated that staff respect them as individuals and felt that smoking was the only rule of the home. Members of staff stated that a rolling menu is followed and the records of meals provided indicate that three meals are served each day. The record also demonstrates that snacks are served between meals and the diet served is varied and wholesome. The range of frozen, canned and fresh foods reflects the menus in place. Residents giving feedback stated that the meals are good and in sufficient quantities. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Care plans must be reviewed to ensure the staff at the home meets residents changing needs. Members of staff monitor residents health care needs are monitored at the home. A record of medications administered by the staff at the home must be maintained. EVIDENCE: The service provider reported that the residents accommodated are able to manager their own personal care needs. Care plans describe the persons physical care needs and the actions to be taken by the staff. Members of staff generally prompt residents to maintain their hygiene. Care plans require reviewing to ensure care plans are appropriate to meet their changing needs. Residents currently have input from psychiatrist and visits are arranged depending on their level of need. Five residents have Community Psychiatric Nurse (CPN) involved in their care. Two residents visit health centres for the administration of medication and one person’s CPN visits the home to administer medications. The residents are registered with a local GP and health checks are being undertaken. Residents have access to local NHS facilities; the optician visits the residents at the home annually and residents visit the local dentist. One resident has continence difficulties, which the service provider stated is Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 14 behavioural and not medical. Residents confirmed that when they visit their GP’s, staff accompany them. Staff use running reports to record outcomes of GP’s visit. A record of health care appointments is kept, with the date, type of visit and the staff that accompanied the person. One resident currently self administers their prescribed medications, with staff administering regular prescribed medications to all other residents. Medications are administered through a monitored dosage system for all residents, with the exception of one person. For one resident, medications are dispensed by the hospital and for this reason computer generated medication administration record sheets, are not provided by the pharmacist. The service provider must ensure that a record of medications administered is maintained for each person at the home. Homely remedies are not administered from stock supply when required. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents know who to approach with complaints, the service providers must consider the accessibility of the procedure to residents and its format. The inhouse Adult Protection policy must follow “No Secrets” guidance to ensure residents are safeguarded from abuse. EVIDENCE: The residents consulted stated that they would approach the service provider with complaints. The service provider stated that the residents are able to verbalise their complaints to the staff, social workers and Community Psychiatric Nurse (CPN). The accessibility of the procedure must be assessed and the format must be considered to ensure residents can understand the procedure for making complaints. There were no complaints received at the home since the last inspections. The home’s Adult Protection policy must reviewed to reflect the “No Secrets” guidance. Existing staff have attended external Safeguarding Adults training and new staff will attend within three months. Members of staff on duty confirmed that they have attended Safeguarding Adults training. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The service provider ensures that repairs are addressed promptly to maintain a homely environment. The bathroom window must be repaired. EVIDENCE: Rosemary care home is situated off the Fishponds Rd. close to shops, places of worship and parks. Originally, the property was two separate domestic dwellings converted to provide accommodation to ten adults with mental health care needs. The property retains its domestic appearance, blending with its immediate environment. It was understood from the service provider that since the last inspection, the bats were replaced and the upstairs bathroom was refurbished. The damp in the downstairs en-suite bedroom is being addressed and once the problem is resolved, the sharing room will become single occupancy. During the tour of the premises, it was noted that the window in the downstairs bathroom is in need remedial action. With one exception, bedrooms are arranged into singe occupancy. Residents bedrooms were found to contain a combination of the home’s furniture and personal belongings. Residents confirmed that keys to bedrooms are provided. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 17 Shared space consists of a lounge and two dining rooms, one of which is used as a smoking area by residents. The laundry room is adjacent to the kitchen; it has a tiled floor and walls for easy cleaning. The washing machine and tumble dryer are domestic in size and recently replaced. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Urgent action needs to be taken to ensure that recruitment procedures are more robust so that it protects vulnerable adults. Steps are taken to ensure staff have the skills to meet residents changing needs. A training programme must be developed to ensure staff undertake appropriate training. EVIDENCE: Five members of staff were recruited through an overseas agency and application forms, two written references and police clearance are kept in their personnel files. From the examination of the records, one member of staff is without a CRB disclosure. The Department of Health “allows applicants who have applied for a CRB check, to start work as a care worker under supervision if they are not on the Protection of Vulnerable Adults (POVA) list.” For this person to continue working at the home, POVA first checks must be conducted and must be supervised while the CRB checks are in progress. This is a matter of serious concern and urgent action must now be taken by the service provider to ensure that CRB are obtained. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 19 The service provider stated that the homes routines and the ethos of the home are discussed with new staff. Formal supervision that focuses on personal development and performance must be introduced for all staff. In terms of recently employed staff, supervision must incorporate induction training, which leads onto Foundation Training. Members of staff are not currently provided with copies of the General Social Care Code of Conduct (GSCC). Copies of the GSCC must be provided to each member of staff. A two-day course on Mental Health Awareness is booked for staff to attend. Dealing with aggression and violence is organised for two staff, with other staff attending at a later date. A training programme that leads into vocational qualifications which incorporates induction, statutory training, and other courses relevant to the needs of the residents must be developed. Members of staff were consulted about access to training, it was stated that external training is scheduled and they were positive about attending challenging behaviour training. Members of staff from overseas would like to convert their nurse qualifications in the near future and will be discussing this with the service provider. Other staff are undertaking NVQ level 2 qualification and their assessors visit monthly. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 &42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The service provider has extensive experience in day-to-day operation of care home for people with mental health care needs. To promote the safety of the residents and staff, fire safety checks and practices must be conducted at the stipulated frequencies. EVIDENCE: The service provider and son share the day-to-day responsibilities of the home. Decisions about the directions of the home are jointly made; the service provider has completed NVQ level 4 and has experience with managing the home. Mr Odeh intends to complete NVQ level 4 in the near future. The records that relate to fire safety, policies, procedures, checks and practices were examined. Records indicated that checks and practices are out of date. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 21 To ensure the safety of the residents and staff checks and practices must be conducted at the specified frequencies. Service certificates and documentation of check conducted by the contractors are in place for the gas system and portable equipment. Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 1 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 x x x x 2 x Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 23 no 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 YA6 Regulation 18(1)(a) Requirement a) For residents subject to section under the Mental Health Act, care plans must detail the consequences for any breeches. (Previously required 29/06/05 & 08/02/06), b) Care plans must be reviewed following ICPA and must reflect the individuals likes, dislikes and preferred routines, c) Care plans must be clear about the restrictions imposed, d) Reactive strategies must be developed for residents that misuse drugs and alcohol A record of all medications administered at the home must be maintained. A better link must be developed between care plans and monthly summaries to define the manner in which the individual makes decisions and choices. (Previously required 08/02/06) Risk assessments must be dated and reviewed with the care plans. (Previously required DS0000026565.V304473.R01.S.doc Timescale for action 30/12/06 2. 3. YA20 YA6 13(2) 12(3) 30/09/06 30/12/06 4. YA9 13(4) 30/12/06 Rosemary Residential Care Home Version 5.2 Page 24 08/02/06) 5. YA12 12(1) (b) Residents goals and aspirations in terms of education and occupation must be sought as part of a person centred approach to meeting residents needs (Previously required 08/02/06) An enhanced level CRB Disclosure must be obtained for each staff member. (Previously required 08/02/06) The accessibility and format of the complaints procedure must be considered The home’s Adult Protection Policy must reflect “NO Secrets” guidance To promote the safety of the residents and staff, fire safety checks and practices must be conducted at the stipulated frequencies. 30/12/06 6. YA34 19 30/09/06 7. 8 9. YA22 22 13(6) 17(2) Sch. 4.14 30/10/06 30/10/06 30/09/06 YA23 YA42 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 Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Rosemary Residential Care Home DS0000026565.V304473.R01.S.doc Version 5.2 Page 26 - 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!