Inspection on 10/10/07 for Rosemount Care Home Limited

This inspection was carried out on 10th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosemount Care Home Limited 24/09/08

Rosemount Care Home Limited 19/06/07

Rosemount Care Home Limited 07/11/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rosemount Care Home Limited 133 Cheadle Old Road Edgeley Stockport Cheshire SK3 9RH Lead Inspector Steve Chick Unannounced Inspection 10th October 2007 11;45 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 Rosemount Care Home Limited DS0000067305.V352825.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. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemount Care Home Limited Address 133 Cheadle Old Road Edgeley Stockport Cheshire SK3 9RH 0161 477 1572 0161 480 3320 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) Rosemount Care Home Ltd Mr Komal Nagjee Coorjee Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 17 service users to include: *up to 17 service users in the category of OP (Old age not falling within any other category). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 19th June 2007 2. Date of last inspection Brief Description of the Service: Rosemount Care Home is a detached residence in its own grounds, situated in Edgeley, Stockport. Rosemount is registered to provide accommodation and care for up to 17 service users. Rosemount has a large lounge, which adjoins a smaller lounge. Access to the gardens can be gained this way, down steps. The smaller section of the lounge was described as the quiet lounge. Four steps leading from the lounge access the dining room. Handrails are provided to both sides of the steps. Due to the design of the care home it is not practicable for people who have difficulty walking up and down steps or who need to use a wheelchair. The home offers single and shared bedrooms. Some of the shared bedrooms were small and offered limited space. En-suite facilities are not provided but there are two toilets for service users use on the ground floor and three on the first floor. There are two bathrooms, one of which had a shower attachment in the bath. One of the baths has a fixed hoist. There is a stair lift for service users to access the first floor of the home. The home is privately owned and has changed ownership in May 2006. The home has a statement of purpose and service user guide which were reported to be given to prospective service users or their families when they visit the home to look round. A copy of the service user guide was contained in service users’ bedrooms. The current weekly fees range from £326 to £333, dependent on the individual care needs of people living in the home. Further details regarding fees are available from the manager. Additional charges may also be made for hairdressing and other personal requirements. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced site visits to the home. All key standards were assessed. This report also uses information gathered since the last key inspection. Everyone spoken to during the visit was positive about the care provided at Rosemount. Visitors reported that their relative had originally come for a period of respite care, but then did not wish to return home. Another service user confirmed that she had visited several other homes but came to Rosemount as she liked it best. Since the last key inspection we have received no complaints about Rosemount. For the purpose of this inspection three service users were interviewed in private, as were two relatives of a service user and a visiting health care professional. Additionally discussions took place with the manager and two members of staff were interviewed. The inspector also undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation including staff rotas, medication records and the complaints log. What the service does well: One service user commented that the pleasant, calm atmosphere apparent at the time of the visit was typical of the home and was not put on for the benefit of the inspection. Another service user cited that the best thing about the home was being well looked after. Within the context of communal living Rosemount maintains a high level of personal choice for the people living there. Staff work well with community-based medical services to ensure that service users health needs are appropriately met. A range of social and recreational activities are available for service users to participate in if they so wish. All service users commented positively on the provision of food. Accommodation is now provided in a homely and well maintained environment. Friendly relationships are maintained with competent and welcoming staff. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 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. Rosemount Care Home Limited DS0000067305.V352825.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 Rosemount Care Home Limited DS0000067305.V352825.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): 3 and 6. Quality in this outcome area is good. Service users needs are appropriately assessed before moving to the home, to ensure that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A selection of service users files was looked at. All had a copy of assessment which had been undertaken by an appropriate professional, before the service user was admitted to the home. It was reported that only one service user had been admitted since the last inspection report was written. This file was seen and included documentary evidence of a written assessment which had been undertaken by the home before a decision was made that the service users needs could be met. This was in addition to an assessment undertaken by the social services department. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 9 No evidence was seen which would indicate that service users needs were not being appropriately met. Rosemount does not offer intermediate care. Rosemount Care Home Limited DS0000067305.V352825.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): 7, 8, 9 and 10. Quality in this outcome area is adequate. The manager cannot consistently demonstrate that all service users needs are met at all times. Service users health needs are met by the consistent implementation of the homes policies and procedures. Staff practices serve to promote the dignity of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A selection of service users files was looked at. All had a written copy of a care plan and there was documentary evidence that the written care plan was periodically reviewed. The care plan format allowed for a wide range of factors to be considered when planning the care for an individual. There was also documentary evidence in some files seen of reviews having been undertaken Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 11 with the involvement of local authority social workers, which recorded positive outcomes for the service users. Some examples were seen where they were anomalies in the documented information which did not appear to have been identified and rectified. For example, one pressure sore risk assessment scored the service user as being at risk whereas the comment stated that the service user was not at risk. This discrepancy in the assessment did not appear to have been explored. Some written risk assessments were seen where the strategy to minimise the risk was not achievable in the context of the care home. In the examples seen there was no increased risk as a consequence of the strategy, but it discredited the significance of the documentary records. The daily records which were maintained were also inconsistent. Some examples were seen which provided good evidence that appropriate care was being maintained. For example, one entry noted that X was fed up after lunch, X came from a walk with me round the garden. Another example was seen where a service user was noted as having a pain in the knee on one day and the following days record included a specific reference to the fact that the pain had cleared up. Examples of less good recording were seen, including a reference to a service user being toileted where there was no evidence in the assessment or care plan that the service user needed assistance to go to the toilet. There was good documentary evidence that service users were regularly weighed. The purpose of this is to ensure that changes in weight which may be an indicator of other health problems or lack of appropriate nutrition are identified at an early stage. Examples were seen where potentially significant recorded weight changes did not appear to have triggered any action. In one example seen a weight gain of 12 lbs was recorded in a six-day period. Examination of the record suggested that this was not, in fact, true but came about due to recording error. The concern was that this had not been identified as something warranting further exploration. There was not good documentary evidence that service users were involved in discussion about their care needs and how those needs should be met. However, service users who were asked reported that they felt that they were involved in the way in which care was offered to them. One service user said staff treat you well [they] dont intrude if you dont want them to, but are there if you need them. … you are not overpowered with help, its a case of what do you need doing? Staff who were interviewed reported that service users were involved in discussion regarding their care plan and that they could read their plan whenever they wished. Staff also reported that in addition to the documentary records there was a verbal hand over at each change of shift. Staff reported being confident that the combination of the written records and information Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 12 passed on verbally ensured that they were aware of the specific care needs of each individual service user at all times. All service users spoken to during the visit were positive about the care they received. Similarly relatives and a visiting professional who were spoken to, reported positively on the way in which needs were met. One visitor commented that since moving to the home their relative was looking better and had put on weight. Service users, staff and visitors who were spoken to during this visit were all confident that service users had appropriate access to the full range of medical and paramedical services available in the community. A visiting health professional was talked to, who was confident that staff followed their instructions and made referrals to them in a timely and appropriate manner. Rosemount uses a pre-dispensed, monitored dosage system for the administration of medication. Medication was seen to be stored appropriately and there was evidence that staff had been trained in the administration of medication. A sample of medication administration records was looked at and they presented as being appropriately maintained. All visitors, staff and service users who were asked, expressed the view that staff treated service users with respect and maintained their dignity. One service user said staff treat everybody good … [they are] kind and considerate and show respect. Another service user, when asked if they were treated well, replied - I wouldnt stay if I wasnt!. Rosemount Care Home Limited DS0000067305.V352825.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): 12, 13, 14 and 15. Quality in this outcome area is good. An appropriate range of activities was available for service users, and visitors are welcome in the home, which enhances service users fulfilment and social stimulation. The provision of food to maintain service users health and well-being is good and service users are able to maximise their autonomy within the context of communal living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the written care plan format used at Rosemount there are sections for identifying social activities care plan and factors to maximise contentment. Examples were also seen where somebodys personal history was well recorded. This would assist in reinforcing the individuality of each service user. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 14 Service users spoken to confirmed that entertainers occasionally visited the home and that a range of activities was provided that people could participate in if they wish. On the afternoon of this visit several service users were observed making models out of sourdough. Examples of previous model making activities were seen in the lounge. One service user spoken to said they have always got something going on in the sitting room - they seem happy lot. Staff who were spoken to, also confirmed that activities did take place regularly, particularly in the afternoon. The visiting professional was also able to confirm that there were often activities taking place when they visited. There was documentary evidence of entertainers visiting the home and occasional outings. An activity chart was maintained for each service user, but as with several other areas of recording, needed to be more rigorously maintained to accurately reflect the social activities with which each service user had participated. The home has a policy of allowing visitors at any reasonable time. This was confirmed as being put into practice by service users, visitors and staff who were spoken to. Some visitors spoken to described the staff as very pleasant and welcoming, and were appreciative of always being offered a drink when they arrived. Service users and visitors who were spoken to confirmed that visits could take place in private. Service users who were spoken to during this visit all expressed the view that they had freedom of choice in terms of how they spent their day. Service users were able to get up and go to bed when they wished and similarly could use any of the communal facilities or their own rooms whenever they wished. One service user cited as the best thing about Rosemount and that there was nobody over your head saying do this or do that. We all got on very well together. another cited as the best thing [you] can do your own thing, not tied into keeping up with the Joneses. There is always something happening and they take us out to the pub. Service users were complimentary about the food which was provided by Rosemount. The documentation in respect of each service user included a dietary preferences sheet. One service user described the food as excellent. They were also complimentary about the new chef and was appreciative that there was a nice variety of meals on offer. Another service user commented that staff knew their likes and dislikes and that a survey had recently been undertaken to establish service users views of the menu. Another service user also confirmed being asked about the menu and that they had noticed a change following that consultation. During the visit a meal was sampled. This was pleasantly presented and tasty. Some service users were observed receiving assistance at lunch which was being given sensitively and appropriately. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 15 There was a menu pinned to the noticeboard in the dining room, which listed the ‘planned’ meals over a period of weeks. The food which was being provided at lunchtime on the day of the visit was different to that on the written menu. The menu itself was in relatively small print and it is unlikely that service users would have been able to use that to influence their choice. It was recommended that a larger notice board with the days menu choices legibly written, could offer service uses a more meaningful choice. Staff maintained a record of what food was chosen by each service user, which did indicate that sometimes some service users exercised their right to choose. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users are confident that any complaints they may have would be dealt with appropriately and they are protected from abuse or exploitation by the homes policies and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users and visitors spoken to during this inspection visit expressed confidence that any complaint would be taken seriously. Although service users who were spoken to had no complaints one said I talk to Ken (the manager) and get it sorted out. another service user expressed the view that they would not mind telling staff if something had gone wrong and was confident they would listen and do something. Staff who were spoken to at this site visit were confident that both they and management would deal appropriately with any complaint. Visitors who were spoken to also expressed confidence that the staff would deal appropriately with a complaint. They also described good open communication and friendly relationships with staff, all of which would serve to make complaint resolution easier. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 17 The home maintained a log of formal complaints. This indicated that one complaint had been investigated by Stockport social services and had not been upheld. It was recommended that maintaining a written record of informal complaints and comments may offer the management of the home a more comprehensive overview of any patterns of small complaints. All service users spoken to at this inspection expressed the view that they were safe at Rosemount, as did all visitors spoken to. Staff who were interviewed expressed the view that service users were safe in the home and demonstrated an understanding of the need to be vigilant and of whistleblowing procedures. Some, but not all, staff had benefited from specific training around the protection of vulnerable adults. The manager reported that there had been a misunderstanding about the booking of further training in September 2007 and that he was to meet with a training partnership in October, to address this matter. A copy of the local authorities ‘all agencies safeguarding adults policy’ was available in the home. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 16. Quality in this outcome area is good. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During this visit a tour of the building was undertaken. This included communal areas and a selection of service users bedrooms. Based on evidence provided in the previous inspection report and on discussion with service users, staff and the manager, it was clear that significant improvements had been made to the fabric and decor of the building. This included new carpets in many bedrooms and in the communal areas, and a Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 19 range of new furniture. Service users who were spoken to were pleased with their accommodation and commented positively on the improvements made. The manager reported that these improvements were continuing and although there had been some delay in, for example, improvements to bathrooms this work was still planned for the near future. At this unannounced visit the home presented as being clean and tidy with no unpleasant odours. All service users, staff and visitors spoken to confirmed that this was the usual state of the building. Visitors cited as among the best things of the home the fact that it was homely and friendly. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. The number and skills mix of staff on duty promotes the independence and well-being of service users. Recruitment procedures are not always applied with sufficient thoroughness to minimise the risk to service users of inappropriate staff being employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the staff rota for the week beginning 01/10/07 was looked at. This demonstrated that between two or three care staff were on duty during the day, and one carer at night with an on-call system in case more support is needed. Staff were spoken to, in private, expressed the view that the staffing levels are appropriate to the number and dependency of service users present. Similarly no service user or visitors spoken to identified staffing levels as being inadequate. Records maintained at the home indicated that of the 12 care staff five held NVQ II or III. It was also reported by the manager that one member of staff who did not have an NVQ, held a nursing qualification (not obtained in United Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 21 Kingdom) and that further places on NVQ training were being applied for. A list of training undertaken by each staff member demonstrated that the majority of staff had received appropriate basic mandatory training. Staff who were interviewed reported that the manager did encourage and enable staff to pursue training opportunities. A small selection of staff files was looked at. There was documentary evidence that some staff had commenced work before obtaining either a criminal record bureau disclosure or POVA first disclosure. The gap between commencing work on receipt of the appropriate disclosure only amounted to a few days and the manager reported that during that period staff are undergoing induction and were never alone with service users. The regulations are quite clear that even with this degree of supervision no person should be employed to work in the home without the legally required disclosure being obtained. In one example seen references were not signed by the referee. The manager reported that this was because they had been received as attachments to emails. There was no record of what steps, if any, he had taken to verify the authenticity of these documents. Service users and visitors were positive about the competency and attitude of the staff. The visiting professional described the care as fabulous. One service user reported that “everybodys friendly - including staff”. This service user described the staff as very good and one other cited being well looked after as the best thing about living at Rosemount. Service users who were talked to reported that, in their view, the staff treated all service users equally well. Staff who were spoken to described supportive colleagues who are expected to, and do, support each other in their work. Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. The management of the home strives to promote the health, safety and wellbeing of people living there but needs more rigour and consistency to ensure that best `practice can always be demonstrated for the benefit of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager reported that due to the nonavailability of the RMA (registered managers award) assessor, the qualification had not yet been confirmed. He hoped that the necessary work and assessment would be completed by December 2007. It was clear from evidence identified at this visit, compared Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 23 with the previous inspection report, that the management in the home had made significant improvements to the running of the home. However there were still areas which needed improvement, particularly in effective management control over the quality of recording and documentation. Concerns identified about teambuilding within the home at the last inspection report presented as having been resolved. There was documentary evidence of a relatives meeting having taken place on the 20th of August 2007, and a staff meeting on the 28th of August. There was documentary evidence of questionnaires being sent out in connection with quality assurance, in July 2007. Eight had been returned. There was no formal, documented analysis of the questionnaires, but the manager reported that issues raised in the questionnaires had been addressed. Specifically this related to alterations to the menu, and was confirmed in discussion with service users. A selection of records relating to money held by Rosemount on behalf of service users was looked at. These presented as being appropriately maintained and included receipts for purchases made on behalf of residents. With the exception of improvements needed to risk assessments relating to individual service users, the majority of issues relating to health and safety within Rosemont presented as being appropriately maintained. One radiator was seen which was not covered, nor appeared to have a low temperature surface. The manager reported that he was aware of this and that the matter would be resolved shortly. Records of tests to the fire detection and alarm systems presented as being appropriately maintained. The training matrix supplied indicated that most staff had received appropriate training in fire safety, first aid, food hygiene and infection control. Staff who were interviewed confirmed the availability mandatory use of personal protective equipment such as disposable gloves and aprons to minimise the risk of cross infection. Rosemount Care Home Limited DS0000067305.V352825.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 3 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation 19 Requirement In order to minimise the risk of exposing vulnerable service users to inappropriate staff all the legally required vetting procedures must be rigorously implemented before the prospective staff member undertakes any tasks or activities within the home. Timescale for action 15/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations More managerial auditing of documentation should be undertaken to ensure accuracy and consistency in care planning. This will enable staff to better demonstrate that the individual care needs of service users are being consistently met. The daily menu choice should be more prominently displayed to encourage service users to exercise choice over their meals, if they wish. 2 OP15 Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 26 3 OP16 The complaints record should be expanded to incorporate informal as well as formal complaints. This would enable the home to identify any patterns of failures of systems within the home so that any remedial action could be taken in a timely manner. The quality assurance system should result in a written plan of action incorporated into an annual development plan. This will enable people to see how their views have influenced the running of the home. 4 OP33 Rosemount Care Home Limited DS0000067305.V352825.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Rosemount Care Home Limited DS0000067305.V352825.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. 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