Inspection on 29/08/08 for Rosemary Residential Care Home

This inspection was carried out on 29th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosemary Residential Care Home 11/09/07

Rosemary Residential Care Home 02/08/06

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 13/11/2008.

CARE HOME ADULTS 18-65 Rosemary Residential Care Home Rosemary Residential Care Home 2 Guinea Lane Fishponds Bristol BS16 2HB Lead Inspector Sandra Jones Unannounced Inspection 29 August & 2nd September 09:30 th Rosemary Residential Care Home DS0000026565.V365187.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.V365187.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.V365187.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.V365187.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 11th September 2007 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.V365187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection was conducted unannounced over two days in August/September 2008 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection including the Annual Quality Assurance Assessment (AQAA). This information was used to plan the inspection visit. “Have your say” surveys were sent to the people living at the home and health care professionals. Five surveys were received from people living at the home and two Health Care professionals in advance of the inspection. There are seven individuals living at the home and four were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the people living at the home and staff were gathered through face-to-face discussions. What the service does well: One person made the additional comment through the survey, “I want to stay here, I am very happy here” A healthcare professional said that the home “Seeks advice from external agencies” Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 6 Individuals said that they were treated with respect by the staff, their needs were staff and had input into their care plans. It was also stated that they knew how to make complaints and felt safe at the home. Members of staff have a clear insight into the needs of people with mental health care needs. They said their awareness was raised because of specific training attended. What has improved since the last inspection? What they could do better: There are seven requirements arising from this and one from previous inspections. One requirement was not checked because access into the bedroom was not possible. The risk assessments for people that are under section of the Mental Health Act must include the actions that staff must take for breeches of restrictions imposed by the section. This will ensure that staff are consistent with the way they manage breeches of section. Care plans for people that are supported with independent living skills must include the person’s abilities and agreement with meeting the goal and the staff actions. This will ensure that staff are supporting the person to achieve the goal of moving into more independent living environments. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 7 Menus would benefit from being more varied. At present the people at the home have the same vegetables frequently and the choice must be more varied. Applications forms must request the name of two referees, one of which must be the most recent employer and referees must be asked to validate the reference. This will ensure that people employed at the home are suitable to work with vulnerable adults. A Quality Assurance System must be introduced, this will ensure that the home is subject to ongoing monitoring and feedback from people at the home is used to improve the standards of care at the home. Fire risk assessments must be reviewed to ensure that the potential for fire is assessed in every room to then develop a plan that prevents an outbreak of fire 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. The summary of this inspection report can be made available in other formats on request. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): (2) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There is an effective admissions procedure in place, which enables people wishing to live at the home to make an informed choice about moving there. They can be reassured that the home will have the skills and resources to meet their assessed needs. EVIDENCE: There is an up to date Statement of Purpose which states that the aims and objectives of the home are to be direct by the needs, abilities and aspirations of the people living at the home. It is confirmed that people wishing to live at the home are provided with information about the home, introductory visits are encouraged and trial periods are offered. This is to ensure that people have information to make decisions about moving into the home. The Admission procedure is contained within the Statement of Purpose and states that admissions are based on needs assessments. Where the Local Authority places individuals, a needs assessment must be provided through the care management process. Full assessments are conducted by the home Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 10 for people that fund their placements and are based on health and social care needs. The case record of the person that moved into the home most recently was examined to establish that the process followed ensures that their needs can be met. The care plan from the Care coordinator shows that an assessment of needs took place before admission to the home. Daily records support that people visit the home before admissions to the home. The service provider said that there was a review meeting following the trial period and the review minutes are pending. Records in place show that the home’s admission procedure was followed and through the procedure the needs of the people wishing to live are assessed ensuring staff have the skills to meet the individuals needs identified. The five people that responded through surveys stated that they were asked if they wanted to move to the home. It was also stated that sufficient information about the service was provided so that they could make choices about moving to the home. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): (6), (7) & (9) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home has failed an effective care planning systems and individuals benefit from receiving an individualised and consistent service. They can expect to be involved in making decisions about all aspects of their care. EVIDENCE: Each person has an Integrated Care Programme Approach (ICPA), which is reviewed by the care manager, with the person, home staff, health and social care professional and where appropriate their relatives participating. From the ICPA, home’s care plans are developed and include personal information, contact details and assessments of needs. The individual’s assessment needs are listed in the care plan, with the actions to be taken to meet the need and Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 12 daily summaries. Daily summaries describe the individual’s likes, dislikes and preferred routines indicating a person centred approach to meeting needs. There is a mental health component in the care plans and described are the need, the section under the Mental Health Act and restrictions imposed by the section. While the information included is clear about the triggers, symptoms and consequences for breeches of restrictions, the action that staff must taken be not included. For example, the action staff must take if a person refuses medication. Care plans are monitored monthly by staff with the person present and the signature on the review plans confirms the person’s agreement with the comments, findings and progress. Two people were consulted about their understanding of care planning process. One person said that there is a care plan review meeting every six months and staff know how to meet their needs. Members of staff were consulted about their input into the care planning process. It was stated that it’s their responsibility to formulate care plans, associated risk assessments and attend reviews. There has been a vast improvement in the care planning, they are more specific about the needs and guide the staff on the actions to be taken. The service provider said that the people at the home are able to express their wishes and feelings verbally to the staff. Two people currently have advocates involved and others have social workers involved in their care. Senior staff said that risk assessments for people at the home are based on their mental health care need, alcohol and drugs. Risk assessments in place and focus on violence, suicide, self-harm and abuse. For each area of need identified, the risk indicators are assessed, with additional comments to explain or clarify the behaviour exhibited. An assessments of the risks identified is then conducted to develop an action plan that contains the identified risk, the triggers and signs of a deteriorating mental health. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): (12), (13), (15), (16) & (17) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People at the home have support to lead active lifestyles. Documentation must be detailed about the way individuals are supported to gain independent living skills. A more varied diet must be provided. EVIDENCE: Activities, occupation and education form part of the care planning process. Individuals Care Programme Approach (ICPA), home’s care plans and reviews illustrate that people at the home have opportunities to undertake meaningful activities outside the home. One person expressed a wish through the ICPA to move into independent living. However, this need is not identified through the care plan. The care plan must be more detailed about the way the home will support the individual to gain independent living skills. Home care plans list Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 14 the activities undertaken by the person and support necessary to attend the activities. Monthly reviews conducted by the staff with the person describe the progress made with activities, occupation and education. Senior staff said that three people currently attend structured activities in the community. One person consulted about activities and occupations, said that they attend a day centre every day but this provision will soon be closing. The staff consulted during the inspection said that they have 1:1 time with people and pay board games. People at the home are able leave the home independently and during the inspection, people were observed leaving and entering the home without support from staff. Both people consulted said that they were able to leave the property without staff support. The five people that responded through surveys said that they always make decisions about what to do each day. One person said `I am free to do as I like The home recognises the importance of maintaining links with friends and family, which is confirmed through the Visitors policy as there is open visiting at the home. Individual’s rights are listed in the Statement of Purpose and described is the way the rights of the people at the home will be respected. The senior member of staff on duty said that the rules of the home are based respecting others, aggressions and leaving the building. The senior member of staff said that these rules would be included in the Statement of Purpose so people wishing to live at the home are fully informed about practices. It was also stated that people undertake household chores that directly affect them, for example, hovering and laundry. People consulted said that they are treated with respect and gave examples of the way the staff treat them with respect. For example, knocking and waiting for an invitation to enter. The staff were consulted about the way they respect people at the home. The staff on duty said that respecting people’s routines, not undertaking tasks without permission, building trust and listening is the ways individuals at the home are respected. A visit from a Food Agency officer was recently conducted and the home was awarded three stars. There is a good range of frozen meat and vegetables with fresh salad and tinned foods. A record of the food served at the home is maintained and people have a varied diet. However, frozen mixed vegetables are served regularly and more varied vegetables could be served. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 15 People consulted about the food said it was good and they have enough to eat. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): (18), (19) & (20) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People can expect sensitive and prompt support for their personal and Health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: The service provider said that the people at the home need little support with personal care. Mainly staff assist people with drying, or filling the bath with water. A senior member of staff said that people at the home have annual health checks and one practice provided Pre-health assessments checklists for people to complete. A separate record of health care visits is maintained and shows that people visit GP’s and have input from psychiatrists. People can also access NHS Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 17 facilities, regular visits to local dentists, opticians and, chiropodists are arranged. Records in place also show that where appropriate staff accompany people on health care visits to the GP’s and hospital appointments. A health care professional that visits the home responded through the survey about standards of care at the home. This professional said that the care service seeks advice and acts upon it to improve the individual’s health care need. It was stated that monthly client meetings are arranged to discuss health care need. It was also stated that there are medical and psychiatrist reviews every six months. Individual medication profiles are in place, which lists the prescribed medication along with the purpose and side effects. Prescribed medications are administered through a monitored dosage system. The records of administration were checked and staff sign the records after administering medications and use codes to record reasons for not administering medications. Medications were checked against the records and they corresponded with each other, supporting that medication systems at the home are safe. Homely remedies are not administered from a stock supply when required by the person. The people consulted about health and personal care described the support provide with personal care by the staff. People explained that staff mainly prompt with personal care, they are accompanied on health care visits and they administer medication. Members of staff comment support individual’s feedback regarding personal care and health care. Staff also stated that medical advice is recorded in the communication book and discussed during handovers to ensure directions are followed consistently. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): (22) & (23) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The Complaints procedure is included in the home’s Statement of Purpose and aims to encourage discussion before more serious complaints are raised. It confirms that comments or complaints will be taken seriously, investigated and complainants will be informed about the actions to be taken. Where complainants are not satisfied with the outcome, CSCI contact details are given as an external body that will investigate unresolved complaints. The service provider is aware that CSCI do not investigate complaints and will be amending the procedure accordingly. A member of the public made one complaint to the CSCI and the complaint was passed onto the home and social worker to investigate. This complaint has been investigated and the complainants desired outcome has been achieved. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 19 Members of staff were consulted about the way individuals at the home are assisted to make complaints. Staff said that complaints made by people are recorded in the complaints logbook and passed onto the service provider. The five people that responded through surveys said that they knew who to speak to if they were not happy and four said they knew how to make a complaint. It was stated through the surveys that staff would be approached with complaints. Equal Opportunities, Whistle Blowing and Protection of Service User policy are available and underpin the home’s commitment to safeguarding people from abuse. These procedures ensure that the approach sets the home’s values and principles. The Equal Opportunities policy shows commitment to building a workforce that reflects the community. Through the Whistle Blowing policy staff are informed that it’s their duty to report poor practice and reinforces that staff will be protected from reprisals. In terms of the Protection of Service Users, the policy describes the factors of abuse and the actions to be taken including the contact details of the agencies to be contacted for alleged abuse. Members of staff consulted said that they had attended Safeguarding Adults training and were clear about the factors of abuse and the actions to be taken. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): (24) & (30) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. The service provider ensures that repairs are addressed promptly to maintain a homely environment. 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. Since the last inspection a number of bedrooms and bathrooms were refurbished since the last inspections. Not all areas of the home were viewed Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 21 during the inspections and, two people refused to give access into their bedrooms. Shared space consists of a lounge and two dining rooms, one of which is used as a smoking area by people at the home. 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. The five people that responded through surveys said that the home is always clean and fresh. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 22 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. 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 this service. For people at the home to benefit from a skilled staff team, staff must be suitable to work with vulnerable adults and must be well supervised. EVIDENCE: The personnel files of the staff employed at the home since the last inspection were examined to ensure that there is a robust recruitment procedure. Criminal Records Bureau and POVA first checks are conducted to ensure the staff employed are suitable to work with vulnerable adults. References were not available for three staff and the others were not from the previous employer. References from previous employers will give the service provider an indication of the staff’s abilities and competency in their previous role. Also the home is breeching their own policy as they are offering employments without satisfactory references from previous employers. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 23 The home’s application form does not currently request the names of two referees and referees are not requested to validate the reference. New employees undertake the Skills for Care Common Induction Programme. Completed logs of the induction programme confirm that staff have a 12 week structured start for the service provider to audit the skills, knowledge and experience of the new employee. The service provider stated that the Common Induction Programme could lead into vocational qualifications. Appraisals and supervisions were recently introduced and each member of staff has attended an appraisal session with senior staff. Staff signed a supervision contract based on expectations and objectives and through the appraisal, personal development goals and action plans are set. The senior member of staff acknowledged that individual supervision with staff must occur regularly to discuss performance and training needs. Training records were examined and indicate that staff attend statutory, refresher and specific courses that meet the needs of the people at the home. First Aid, Food Hygiene and fire training was recently provided and some staff have attended Safeguarding Adults training. Five staff have attended Mental Health Awareness training and senior staff have organised further Safeguarding Adults, Person Centred Planning and Equalities training. Senior staff are aware that all staff must attend Mental Health Awareness training to ensure all staff have insight into the needs of the people accommodated. Members of staff’s feedback was sought about training. The training described the training attended since the last inspection and said that vocational qualifications will be undertaken next year. The health care professional that responded through the survey said that staff have the skills and experience to support individuals social and health care needs. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): (37), (39) & (42) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. Individuals will benefit from a well managed home, once systems Quality Assurance Systems and fire risk assessments are further developed. They can then expect to live in a safe environment and can be assured that standards will be the subject of ongoing monitoring, including input from their own views EVIDENCE: The staff at the home were consulted about the management style in use at the home. It was stated that the service provider and senior staff participate in “hands on” care, have an open and approachable style and suggestions are taken seriously. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 25 The five people that responded through surveys said that they were treated well by the staff and they listened and acted upon what they said. The rota in place was checked and shows that senior staff are rostered during the week. Staffing levels are high with up to five staff between 9:00 – 6:00 pm, when the levels fall to three staff until 8:00 pm. At night there is one staff sleeping-in the premises. Fees charged at the home range from £2124.70 - £560.06 per two weeks. Fire risk assessments were undertaken and an action plan was formulated to ensure the property is safe for people at the home. Assessments of each room must be undertaken to assess the potential of fire and from the assessments an action plan must be devised that include the checks and practices that will be undertaken. The service provider also ensures that the property meets associated legislation including annual servicing of the gas boiler and portable equipment. Quality Assurance system was discussed with senior staff and it was acknowledged that a system is not in place and one must be introduces. Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 26 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 2 12 X 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Rosemary Residential Care Home DS0000026565.V365187.R01.S.doc Version 5.2 Page 27 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 Regulation YA9 13 (4) (b) Requirement Risk assessments for people under section of the Mental Health Act must include the actions that staff must take for breeches of restrictions under section. For people that are supported by the staff with independent living skills, their care plans must include the need, their abilities and actions that must be taken by the staff to support the person. The menu must be more varied Make repairs to ground floor bedroom sink. (Not checked at this inspection) Application forms must be amended to request the name of two referees, one of which must be the most recent employer. Referees must be asked to validate the reference. A Quality Assurance System must be introduced Fire risk assessments must be reviewed to ensure that the DS0000026565.V365187.R01.S.doc Timescale for action 30/12/08 2. YA6 15 30/12/08 3. 4. YA17 YA24 16 (2) (i) 23 (2) (b) 30/10/08 30/11/08 5 YA34 7,9, &19 Sch.2.3 19 (4) (c) 24 24(4) 30/10/08 6 7 8 YA34 YA39 YA42 30/10/08 30/01/09 30/10/08 Rosemary Residential Care Home Version 5.2 Page 28 potential for fire is assessed in every room to develop a plan that prevents an outbreak of fire at the home. 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.V365187.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V365187.R01.S.doc Version 5.2 Page 30 - 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. 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