Inspection on 22/04/08 for Rosemont

This inspection was carried out on 22nd April 2008.

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

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

Rosemont 22/04/09

Rosemont 06/12/08

Rosemont 06/06/07

Rosemont 20/07/06

Rosemont 07/03/06

Rosemont 03/08/05

Rosemont 23/02/05

Rosemont 28/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosemont Yealm Road Newton Ferrers Plymouth Devon PL8 1BX Lead Inspector Graham Thomas Unannounced Inspection 09:00 22 and 30th April 2008 nd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rosemont DS0000003798.V361924.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemont Address Yealm Road Newton Ferrers Plymouth Devon PL8 1BX 01752 872445 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) Mr D M Beckhurst Mr D M Beckhurst Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2007 Brief Description of the Service: Rosemont is a care home registered to provide care for 19 people in the category of old age only. At the time of our visit, 14 people were living in the home. It is owned and managed by Mr Beckhurst, who is assisted by another staff member who is known as the “Care Manager”. The home is registered to accommodate up to 19 people. Two rooms have en-suite facilities. The premises comprise a large, older property that stands in its own grounds, overlooking the picturesque creek of Newton Ferrers. There are a dining room, two lounges and a conservatory. The home has a stair lift to the mezzanine level and ramps to provide access in and out of the building. Those service users with limited mobility are provided with accommodation on the ground and mezzanine floors as there are a few steps remaining to access the first floor. Adjoining the property are two privately owned flats that are not connected to the care home. The proprietor and his family live in one flat and the second is used as staff accommodation. Current weekly fees range between £375 and £450. This does not include chiropody, hairdressing or magazines and newspapers Rosemont DS0000003798.V361924.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 the service experience adequate quality outcomes. Before the inspection visit we reviewed our records including correspondence and information sent to us by the Mr Beckhurst. We visited the home on two separate days. On the first day we toured the premises, spoke with people living in the home, staff and Mr Beckhurst. We also looked at records including five care plans, six staff files and various health and safety records. The medication system was also examined. During the second visit we discussed various issues with the “Care Manager” who was on leave during our first visit. What the service does well: What has improved since the last inspection? • • • • Daily records have improved and now show more clearly how people have spent their day and how their needs are changing. People living in the home are now aware that an alternative meal is available if they prefer. There is better control of unpleasant odours in the home. Staff have received training in infection control. They now use better procedures for controlling the spread of infection. DS0000003798.V361924.R01.S.doc Version 5.2 Page 6 Rosemont • There is a better programme of training for staff to improve their knowledge and skills. What they could do better: • • • Risk assessments need to be reviewed regularly and kept up to date so that people are protected from unnecessary risks. Care plans need to be regularly reviewed and updated so that peoples’ changing needs are clearly identified. Improvements are needed in the way the home manages medicines to ensure that the system is safe. The availability of managers needs to be clear so that people know when they can be contacted. Staff need regular supervision to support them in doing their jobs. There needs to be better monitoring of the quality of the service provided. • • • 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. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into Rosemont can feel confident that the home will make sure it can meet their needs before offering them a permanent place. EVIDENCE: We examined the care plans of three people who had recently moved into the home and interviewed one of these people. The person interviewed felt that they had received enough information about the home before moving in. Individual plans contained assessments of people’s needs which had been made before they moved into the home. There was also information which had been gathered as part of this assessment including correspondence and care plans from homes where people had lived previously. Care plans had been produced for two of the people who had recently moved to the home. A Senior Carer stated that she was devising the plan of the third. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 9 Rosemont does not routinely accommodate people whose needs are solely for intermediate care. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Generally, people living in the home receive an adequate level of care and support. However, poor practice concerning the use of medicines continues to pose a potential risk to their health and wellbeing. EVIDENCE: People with whom we spoke said that they were happy with the care they received from the home’s staff they also stated that they could see a doctor or get specialist treatments when required. Each person had an individual plan of care. The contents of the five plans examined was variable. For example, some showed signs of recent review whilst one had not apparently been reviewed for six months. Some plans lacked basic personal details. Some of the documents in the plans had not been signed and dated and some lacked a photograph of the person. Some individual risk assessment had not been reviewed and updated and one was completely blank. One person’s plan indicated that they liked to take a walk in the village but that the person was liable to confusion. There was no Risk Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 11 assessment concerning this activity. It is important that these records are kept up to date so that the person’s changing needs can be properly monitored. The review of risk assessments was the subject of a requirement at the last key inspection. An immediate requirement notice was issued on this occasion. Daily records had improved since the last key inspection. On this occasion they provided more detail about the specific care that had been provided and how the individuals had spent their day. Records showed that people were receiving both routine and specialist health care according to their needs. One person had a particularly high level of need and was being regularly monitored by the local Community Nursing service. This person had equipment and facilities relevant to their needs such as a pressure relieving mattress. The care plan for this person had been recently reviewed and updated and there was a recent moving and handling assessment. We examined the home’s system for administering medicines. A “Nomad” system was in use in which the pharmacy supplies most tablets in cassettes which are organised according to the time the medicine is due for administration. At the time of our visit, medicines were stored in two separate cupboards which were both lockable. One of these cupboards was not secure in that it was possible to reach through a gap below the doors. This cupboard was made secure before the end of our visit. An additional secure container was also fitted during our visit to store any controlled drugs. The records of five people’s medicines were examined. A number of shortfalls were identified. None of the records showed the quantities of individual medicines received from the Pharmacy. In one instance, liquid medication had been removed from its box which was stored separately. There were no directions on the bottle. Printed label on the box stated the medicine was to be administered “as directed” and there were no further instruction available for staff. There were also gaps in the administration record. No record had been made of the quantity of this medicine received from the Pharmacy. One person had been prescribed a medication which was not recorded on the medicines administration record. Another had been prescribed a medication which was detailed on the medicines administration record. However, there was no record of the medicine being administered or why it had not been administered. One person had been administered a medication on several occasions. None of the doses administered had been signed for. Similar issues were the subject of a requirement at the last key inspection. On this occasion an immediate requirement notice was issued. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 12 All the people with whom we spoke regarded staff as kind, helpful and felt they were treated with respect. During our visit staff were observed knocking on people’s doors before entering their rooms. People living in the home were addressed respectfully by staff. Doors were closed when personal care was being given. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Rosemont provides a lifestyle which generally meets the expectations of people living in the home. EVIDENCE: People with whom we spoke stated that they were content with the lifestyle provided by the home. Some mentioned the occasional slide shows which take place in the home. During our visit small groups were seen chatting in the home’s sun lounge and completing a jig saw. Others were seen in the other two lounges watching television and chatting. Some people spent time relaxing in their rooms. A communion service was held during the visit. Mr. Beckhurst stated that this was a monthly event. In addition, some people living in the home were able to attend local church services. The local church also hold a lunch club though nobody was attending these events at the time of our visit. Records were seen concerning an occasional visiting entertainer. We talked with people about their visitors. One person talked about the regular visits received from her children and grandchildren. At these times it was said Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 14 that visitors were always made welcome by staff and that arrangements were flexible enough to suit everyone. All the people with whom we spoke stated that they enjoyed the food provided by the home. We visited the home’s kitchen and spoke with the cook. Menus were examined and the food stores and refrigerated storage were inspected. There was a plentiful supply of fresh vegetables and other food in the dry store, refrigerator and freezer. No choice of meal was offered on a routine basis but all people with whom we spoke stated that alternatives were available if they did not wish to take the meal on offer. On the first day of our visit the meal comprised of fish pie with fresh vegetables followed by bread and butter pudding with custard. The cook was aware of individual dietary needs including those of people with diabetes for whom sugar free sweeteners were used. One person required a soft diet. Liquidising individual portions had been attempted for this person but they appeared to prefer the ingredients liquidised together. During our visit lunch was taken in the dining room by most people living in the home. Some took meals in their rooms according to individual need and preference. Apart from small amounts of petty cash held for individuals, the management of the home is not involved with the individual finances of people living in the home. these are generally managed by families or other independent representatives. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home can feel confident that their concerns will be listened to and acted upon. Improved staff training means that people are better protected from abuse. EVIDENCE: People with whom we spoke felt confident that any concerns or complaints would be listened to and acted upon by staff. The home has an accessible complaints policy and procedure. The Registered Person stated that no complaints had been received since the last inspection and this was reflected in the home’s complaints record. The Commission has not received any complaints or concerns about the home since the last key inspection. Staff had received training about safeguarding people from abuse based on the locally produced “No Secrets” video. Questionnaires had been devised to accompany this video and reinforce the training. Copies of completed questionnaires were seen. Staff with whom we spoke were all able to say how they would alert others to actual or suspected abuse. The home’s policy on safeguarding people from abuse did not conform to the most recent guidance and required updating. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 16 Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Rosemont provides a homely, comfortable and sufficiently safe environment for the people living there. Some risks are not sufficiently well assessed to ensure people’s safety. EVIDENCE: Rosemont is situated on the outskirts of the village of Newton Ferrers. Shops and other amenities are within walking distance. Externally the home has well maintained grounds with ramped access to the garden where seating is provided. The home has a good range of comfortably furnished communal space including a lounge / dining room, a separate lounge, and a conservatory with views of the estuary. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 18 Many of the bedrooms are very large, with one offering a lounge area as well as a bedroom. Two bedrooms provide en suite shower facilities. On inspection, the individual bedrooms were found to be comfortable and personalised with the occupant’s own belongings. All rooms were sufficiently clean and free from offensive odours. There are sufficient bathing and toilet facilities on each floor to meet the needs of people living in the home. Two of the 3 bathrooms are fitted with aids to assist service users with poor mobility. A shower in the ground floor bathroom is used as a storage area. Facilities such as booster seats and toilet frames were seen. The toilet on the first floor does not have a wash hand basin. Waterless gel hand cleaner has been supplied to this toilet to minimise the risk of cross infection. Liquid soap and paper towels were supplied at communal hand basins. Radiators were covered for service users’ safety. One room contained a freestanding heater for which a risk assessment had not been produced. The Registered Person has stated that all baths had been fitted with hot water regulating valves and that these were being fitted to hand basins on the basis of risk assessment. Risk assessments regarding hot water were seen in individual files though some of these required review. Three windows on the upper floor were examined and all were restricted to prevent accidents. The home was generally well-maintained and a maintenance log was available for inspection. Hand basin taps in room 14 were stiff and difficult to operate. The home’s laundry is separated from the kitchen and has cleanable floors and washable walls. Bags were provided for transporting laundry. There were machines for washing and drying. Staff confirmed that the machines had hot wash cycles. A system was in place for the disposal of infected waste. Staff had received training in infection control and those handling laundry were seen to be wearing protective clothing. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28 and 29 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Rosemont can be confident that they will be cared for by sufficient numbers of trained and competent staff. EVIDENCE: We examined six staff files. Training records were inspected as well as staff rotas supplied by the Registered Person. Three staff were interviewed and others were spoken with informally. People living in the home made positive comments about the staff, describing them as “kind” and “helpful”. The rotas we examined showed that between 8:00am and 2:00pm there were two or three staff on duty. This includes the “Care Manager” who supports the Registered Person in the management of the home. There are then two staff on duty until 8:00pm. Between 8:00pm and 8:00am there is one staff member on duty and one on call. The staff on call live in the nearby flats within the grounds. Since the last inspection the staff group has remained stable so there were no recent recruits. At the last key inspection shortfalls were identified in the safety of the recruitment process. Discussions with the Registered Manager since that Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 20 inspection indicate that he understand the requirements of regulation regarding safe recruitment. Staff files contained evidence of an induction based upon the National “Skills for Care” framework. Since the last inspection staff have received training in the form of short courses in topics such as infection control, food hygiene and safeguarding vulnerable people from abuse. A substantial programme of training towards National Vocational Qualifications was also in progress. This included two staff undertaking a course at level 4, five staff at level 3 and one at level 2. The “Care Manager” has completed a Registered Managers Award. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 36 and 38 Quality in this outcome area is, adequate. This judgement has been made using available evidence including a visit to this service. The home is adequately well managed overall. However there is insufficient clarity for staff and people living in the home about management availability. Monitoring and sustained improvement of the home’s systems to ensure the safety and welfare of people living in the home is not sufficient. EVIDENCE: Mr Beckhurst is the Registered person and therefore has overall managerial control of the home. A senior staff member known as the “Care Manager” assists him in this. They have, respectively, 20 years and 10 years managerial experience. The “Care Manager” has completed the Registered Managers award. Mr Beckhurst does not hold this qualification. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 22 The Care Manager takes responsibility for care planning, medication and other areas of care, including the associated administrative tasks. Mr Beckhurst oversees finances, maintenance issues, and other day-to-day tasks. The Care Manager works on five days a week between 8:00am and 2:00pm during which time she is also involved in direct care of people living in the home. Mr Beckhurst has his own accommodation nearby and stated that he is in the home on most days. On the first day of inspection visit, the “Care Manager” was on holiday. We returned on a second day to speak with her and clarify a number of issues about care and management. People living in the home with whom we spoke were not clear about the management arrangements. It was also evident in telephone conversations with staff between the two visits that the arrangements regarding Care Manager’s return were not understood. A quality assurance system was being introduced at the time of the last inspection. Whilst records showed evidence of some auditing of the home’s systems, this work appeared to have been neglected more recently. This was further demonstrated by repeated shortfalls in areas highlighted at the last inspection such as risk assessment and the administration of medicines. Mr Beckhurst stated that the home is not involved in any way in the finances of people living there other than to hold small amounts of cash for safe keeping. Individual finances are managed either by the person concerned, their relatives or other representatives. This was confirmed in conversation with people living in the home. A sample of the cash held was examined. This appeared to be correct and in good order. Records of staff supervision showed that this was not regular. There were no records of any supervision of the “Care Manager”. Staff stated that there were “occasional” staff meetings. Certificates in staff files and other records showed that they had received training in health and safety topics such as food hygiene, and infection control. This was confirmed in discussion with staff. First aid certificates available for inspection at the time of our visit were out of date. However, it was subsequently confirmed that staff have undertaken further first aid training. Records concerning health and safety in the home were examined. Risk assessments for individuals living in the home included such items as hot water in their rooms. However, one room contained a free-standing heater for which there was no risk assessment. This is a repeated shortfall from the last key inspection Some risk assessments had not been reviewed recently. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 23 Other documents showed effective health and safety systems. A recent Health and Safety inspection by South Hams District Council expressed confidence that a comprehensive health and safety management system was in place which was being reviewed and monitored. There were no outstanding issues to be addressed. Invoices and other documents showed evidence of boiler servicing, electrical appliance testing and testing of the home’s smoke detection system. A fire alarm test was carried out during our visit. Hazardous waste transfer arrangements were clearly documented. A maintenance log was available for inspection which showed a programme of ongoing maintenance. This was confirmed by observation when we toured the premises. Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 3 Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4)(c) Requirement The Registered Person must ensure that individual risk assessments are be regularly reviewed and kept up to date in order to protect people from unnecessary risks to their health and welfare (Previous timescale of 31/7/07 not met. Immediate Requirement Notice Issued) The Registered Person must ensure that all care plans are regularly reviewed and updated The Registered Person must ensure that records in respect of each service user contain the information, documents and other records specified in Schedule 3 of the Care Homes Regulations 2001 The Registered Person must ensure that the home’s systems concerning the use of medicines confirm to the guidance of the Royal Pharmaceutical Society. In particular: All medicines administered must be signed for. A clear account must be given DS0000003798.V361924.R01.S.doc Timescale for action 07/05/08 2. 3. OP7 OP7 15(2)(b) 17(1)(a) 01/07/08 01/07/08 4. OP9 13(2) 07/05/08 Rosemont Version 5.2 Page 26 for any medicines not administered as prescribed Where medicines are labelled as directed, clear directions must be sought from the prescribing GP Clear directions for staff must be available regarding any medicines prescribed as required (Previous timescale of 30/6/07 not met. Immediate Requirement Notice Issued) 5. OP38 13(4)(a) A risk assessment must be produced for any free-standing radiator. 01/07/08 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. 2. Refer to Standard OP7 OP32 Good Practice Recommendations Individual care plans and daily records should demonstrate a clear cycle of assessment, planning, action and review. The Registered Person should ensure that people living at the home, their relatives, staff, and professionals are aware of the management arrangements and when managers are available. All staff should receive regular supervision to monitor their practice and identify areas of strength and potential improvement. The home’s quality assurance system should be maintained to identify and address shortfalls and ensure improvements are sustained. 3. 4. OP36 OP33 Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 Page 27 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 Rosemont DS0000003798.V361924.R01.S.doc Version 5.2 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!