Inspection on 26/06/08 for The Rosemary Care Home

This inspection was carried out on 26th June 2008.

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

The Rosemary Care Home 29/03/10

The Rosemary Care Home 03/02/10

The Rosemary Care Home 08/10/09

The Rosemary Care Home 26/08/09

The Rosemary Care Home 03/07/07

The Rosemary Care Home 29/01/07

The Rosemary Care Home 11/07/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Rosemary Care Home The Rosemary Care Home 13 Newhey Road Milnrow Rochdale Lancashire OL16 3NP Lead Inspector Sue Jennings Unannounced Inspection 26th June 2008 11:21 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 The Rosemary Care Home DS0000066311.V365676.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. The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Rosemary Care Home Address The Rosemary Care Home 13 Newhey Road Milnrow Rochdale Lancashire OL16 3NP 01706 650429 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) Din T Vanat Manager post vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability over 65 years of age (1) of places The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 27 service users, to include: Up to 26 services users in the category of OP (Older People) Up to 1 service user in the category of PD(E) (Physical Disabilities over 65 years of age) The service should employ a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection 3rd July 2007 2. Date of last inspection Brief Description of the Service: The Rosemary Care Home is a privately owned residential home, which provides care for up to 27 older people and one person with a physical disability. The home is in the centre of Milnrow and is close to local shops and pubs. It provides good access to the motorway network. The home is on three floors and there is a passenger lift to all levels. Twenty-one single and three double bedrooms are provided. Two of the bedrooms have the added provision of an en-suite. Two lounges and a dining area are provided on the ground floor and a lounge on the first floor, which is designated as a smoking lounge. A bathroom is provided on each floor and a level access shower room on the ground floor. Two of the baths are fitted with fixed hoists. Toilets are located near to lounge areas and bedrooms. A well maintained garden is available to the front of the home where there is also parking. The most recent Commission for Social Care Inspection (CSCI) report was available in the reception hall. The fees were £352-81 per week. The home did not charge a ‘top up’ fee but there was an additional £10.00 fee for an en-suite room. Additional charges were made for hairdressing, trips, newspapers, telephone, alcohol, clothing and personal toiletries. The Rosemary Care Home DS0000066311.V365676.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 two stars. This means that people who use the service experience good quality outcomes. The service had completed an Annual Quality Assurance Assessment (AQAA) sometime before this inspection took place. The AQAA gave the service the opportunity to tell us what they do well, how they had improved in the last twelve months and their further plans for improvement in the next twelve months. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 7.5 hours on Thursday 26th May 2008. During the course of the site visits time was spent talking to a visiting district nurse, the manager, the proprietor, 5 residents and 3 members of staff to find out their views of the home. In addition we received completed survey forms from residents, relatives and staff. The inspector spent time examining records and the residents and staff files. A tour of the building was also made. What the service does well: Comments from people who use the service included “I wouldn’t move anywhere else”, “they look after me too well sometimes”, “this was the very best” and “they are all very pleasant”. Staff were very friendly and polite. This is noticeable when visiting the home and watching how staff interact with residents. The healthcare of people living there is well managed. People living at the home enjoy the food provided. Individuals spoken to reported that staff were friendly and polite. A good programme of training is made available to care staff. Complaints are managed well and the service uses them to make improvements where necessary. The Rosemary Care Home DS0000066311.V365676.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. The Rosemary Care Home DS0000066311.V365676.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 The Rosemary Care Home DS0000066311.V365676.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): 1 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems in place to make sure that people’s needs are assessed before admission. EVIDENCE: There had been twelve admissions to the home since the last inspection. We saw that there is an admissions procedure and that needs assessments are completed prior to anybody moving in. Once an individual comes to live there, a care plan is written based on these assessments. A Statement of Purpose and Service User Guide are available and contain information about the service provided. The guide gives the current fees and any additional charges. People moving in have a trial period of six weeks to see if they like it and to make sure that the service can meet their needs. The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 9 Residents’ files contained assessments of need completed by the placing authority and the home. Residents placed by a care manager had received contracts from the local authority. One person said “once I got here I felt at home” and “the staff are very nice, friendly and very helpful”, “my daughter came to visit the home on my behalf and she found it to be the very best” and “they respond to my every need”. They offer day care for up to three people each day. They told us that this helps people to prepare for residential care and is also beneficial to residents who enjoy the communication and contact. The home did not provide intermediate care. The Rosemary Care Home DS0000066311.V365676.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 good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are met by the home and medication practices safeguard residents. EVIDENCE: We looked at the care plans for five people and the information provided covered areas such as diet and personal care, moving and handling risk assessments, care managers assessment, oral care, religious and cultural needs, daily life and social activities, pressure area risk assessments, dietary needs, likes and dislikes and allergies. Male carers were employed and this gave male residents a choice about whether they wished to have a male carer to assist with their personal care needs. The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 11 All residents were registered with a local GP and where possible residents had retained their own GP. Records of visits from other healthcare professionals were held in each resident’s file. One relative or friend commented in a survey form “Very much a family centred feeling even for the residents who have few visitors. Any requests by family have always been fulfilled by the manager who is very approachable as are the staff”. A resident told us “it is lovely here and he is a good lad” (indicating the proprietor) this one is lovely too (indicating the manager) she comes and chats to us every day”. One relative or friend commented in a survey form “Rosemary is beautifully devoted and continues to be updated on a regular basis. It has a warm and friendly atmosphere. Staff always have a smile on their faces and are always willing to help and have a chat”. One relative or friend commented in a survey form “communication between staff members and cascading down of information needs a little touch-up”. One relative or friend commented in a survey form “Pleasant staff and manager it’s very good” One relative or friend commented in a survey form “The management were very helpful and all questions were answered, my relative enjoys life at the home”. Risk assessments are completed around areas such as falls, pressure areas and nutrition. We saw that these were generally well completed. We saw that district nurses visited the home and a tissue viability nurse is also consulted to advise on good pressure area care. A chiropodist visited the home and some residents chose to visit the chiropodist at the clinic. We saw that some of the daily notes kept by staff were very repetitive and general statements such as ‘fine today” and “all care needs met’. Notes kept by staff should reflect the care delivered. This information can then be used to evaluate and review the care being provided. We saw that medication was dispensed into a blister pack monitored dosage system and was stored correctly. We saw that the receipt and disposal of medication was being recorded and that records were generally kept well. One resident told us “The staff help me when I take my medication”. The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 12 The home works closely with other professionals and specialists for advice and support to help the resident, their family and the home’s staff. A visiting district nurse told us “staff are very helpful, they come round with us and take on board everything we tell them”, “the patients are always ready for us when we get here and they are always really helpful, yes they are all very nice, it is really good here”. The Rosemary Care Home DS0000066311.V365676.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. This judgement has been made using available evidence including a visit to this service. A range of activities is provided and residents are able to maintain contact with family and friends. Residents have a choice of varied, well-balanced meals. EVIDENCE: Staff on duty welcomed us into the home. They told us there was an open visiting policy and residents were able to see visitors in one of the lounges or in the privacy of their own rooms if preferred. One resident told us their visitors were always made to feel welcome and can visit at any time. Other residents said that they were able to have friends and family visit when they liked. There was a relaxed atmosphere in the home and it was evident that residents were able to choose how they spend their days. Residents were able to get up and go to bed whenever they chose to. The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 14 Residents told us that they enjoyed the food offered with comments including “the food is good”, “very good” and ”there are always two choices”. One resident told us, “I don’t like the sandwiches the bread is cheap and it does not taste very nice I prefer wholemeal bread it is tasty” and “I like my food very hot I can’t enjoy tepid food so they microwave it for me”. We saw lunch being served in the dining room it appeared to be a positive occasion and an opportunity for people to talk without being interrupted. Menus were based on a four-week rota and were reviewed regularly to take into account resident’s preferences. The menus were displayed in the dining room and also the cook asked each person on a daily basis what they would like for lunch from the menu choices. This made sure that residents knew what the meal choices were for each day. Residents were able to choose an alternative to the set menu if they did not like the menu choice for the day. We saw that meetings were held with residents and that minutes were kept. It is recommended that they develop an action plan so that where residents raise issues they can see what action is being taken in response to their concerns/ideas. One resident told us that they had a kettle in their room and were able to make a cup of tea whenever they wanted. Ministers from local churches visited the home on a weekly basis. The manager told us that arrangements would be made to support residents from other religious backgrounds as and when required. There is a range of activities on offer to people living there. They told us that three activities co-ordinators visit the home on various days. They work to a weekly schedule, which is displayed in the hallway. Activities include artwork, visiting entertainers, cooking and gardening. We saw photographs of residents taking part in a baking session. Managers and staff encouraged residents to be active and provided a range of opportunities for residents to maintain social/community contacts where possible. One resident told us “we have painting and baking classes and go out on trips”, ” there is something going on most days”. The Rosemary Care Home DS0000066311.V365676.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place to safeguard residents from abuse and people are confident that their complaints will be acted upon EVIDENCE: The policies and procedures had not been reviewed recently to include any new guidance or legislation such as the Mental Capacity Act. A recommendation is made that the policies and procedures be reviewed and where necessary updated. There are suitable procedures in place for dealing with complaints. The complaints policy and procedure is part of the guide for the people living there. The manager told us that there had been two complaints since the last inspection. These had been dealt with appropriately and there was a record of the complaints but nothing had been written about how it was investigated or what the outcome was. It was recommended that a record of the complaint, the investigation and the outcome be kept to keep an audit trail of how complaints are dealt with. Discussion with residents demonstrated that they were clear about how and who to make a complaint to. One resident told us in a survey form “I will speak to the manager or a member of staff”. Another said “I am very comfortable talking to the manager she is very supportive and caring she is always there to listen”. The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 16 The service has internal policies and procedures for the Protection of Vulnerable Adults (POVA) and a copy of the local procedures was also seen to be available. There have been no recent allegations of abuse. There was evidence to show that the manager and staff encouraged residents to maintain contact with family and friends. One resident told us that a relative who was viewing a flat nearby was invited to have lunch with them on the day of our site visit. There was a whistle-blowing policy so that staff knew that the organisation would support them. Post was delivered to residents unopened and information on independent advocacy agencies was displayed in the home. The Rosemary Care Home DS0000066311.V365676.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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are safe and the home’s environment, including the standard of hygiene, was well maintained both internally and externally. EVIDENCE: On the day of the site visit it was raining very heavily and there was a water leak from the flat roof into an unused corridor. The owner had arranged for a workman to repair the damage, who was on site during the inspection. The home had a warm and welcoming atmosphere and felt comfortable and homely. All areas of the home were clean and tidy. We saw that new armchairs and bedding had been purchased and a number of carpets had been replaced. A tour of the building was carried out and it was noted that a number of areas had been redecorated. We saw that some areas of the home still required The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 18 redecoration and updating and the manager told us that there are plans to continue with redecorating the interior of the home. One resident living on the second floor level told us “I go down for tea in the lift” we saw they were able to use the lift independently and enjoyed the freedom this gave them. We saw that there were satisfactory numbers of domestic staff to keep the home hygienic. The home also employed a laundry assistant to make sure residents’ clothing was washed and returned to them as quickly as possible. Residents told us that missing or damaged clothing was “not a problem” and “a we have a someone who does the laundry, it is always brought back within a day or two”. We saw that bedrooms were clean, comfortable and personalised to varying degrees reflecting the character of the resident. One resident who spends a lot of time in their bedroom told us that another resident comes into their room every morning, “sometimes he comes to my bed and wakes me up to ask what day it is”. We saw that the bedroom doors on the top level were not fitted with privacy locks. We discussed with the manager the possibility of having one fitted that gives residents privacy but allows staff access with a master key in case of emergency. It was also of concern that two of the bedroom doors on the ground floor were fitted with ‘star locks’ which posed a risk of entrapment. These must be removed and a more appropriate locking system fitted that can be easily opened by the resident from the inside and over ridden from the outside. Residents told us “its good”, “I am very happy with my room, I used to be in the room next door but they offered me this one because it is bigger and I spend a lot of time here” and “my room is very nice”. We saw a mobile heater and kettle in one resident’s bedroom. A risk assessment must be carried out for both items. It was also strongly recommended residents be asked if they want a lock on the bedroom door. We saw that the bathroom on the first floor had a new shower fitted. The bath panel was broken and posed a risk of injury to residents. This must be replaced. Infection control policies/procedures were in place. At lunch time, staff were seen to change protective aprons to blue ones for serving food. Liquid soap and paper towels were supplied in bedrooms, toilets and bathrooms to try and prevent the spread of infection. The Rosemary Care Home DS0000066311.V365676.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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff was sufficient to meet the needs of the residents accommodated and staff have access to a wide range of training. EVIDENCE: Comments from residents regarding staff at the home included “they are all lovely very helpful”, “the staff are kind they will do anything they can to help”. A sample of staff files was examined. These were well maintained and contained Criminal Records Bureau (CRB) and checks against the Protection of Vulnerable Adults list (POVA). The two newest staff did not have the required references on file. The two members of staff had come from the same care home and there was evidence to show that references had been requested but not chased up. One of these staff had worked in another care home. The manager was advised to approach them again for references. A requirement is made that all new staff have two written references prior to starting work. The other staff member had only previously worked at the other home and the manager was advised to try and obtain a reference as soon as possible. One of The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 20 the staff did not have a CRB but did have a POVA check and they were working alongside another member of staff. Staff files contained photocopied documents, for example passports, utility bills and certificates but there was no evidence that the original documents had been seen. It is recommended that that all photocopied documents are signed to indicate that the original has been seen. Staffing rotas showed that there were enough staff to meet resident’s needs. Staff spoken to said that they had access to training. A training plan was seen that stated training in relation to manual handling, medication, fire safety, First Aid, and Protection of Vulnerable Adults had been provided. Two staff members we spoke to said that they had been nominated for Dementia care training on 30th June 2008 and Palliative care on 7th July 2008. The manager reported that regular staff supervision was provided and all staff completed an induction period. There was evidence on staff files to show that staff were given a copy of their job description detailing their roles and responsibilities. We saw that staff were very caring and spoke to individuals in a polite and respectful manner. The Rosemary Care Home DS0000066311.V365676.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): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s quality monitoring systems protected residents and the home had systems and procedures in place which safeguarded and protected resident’s financial interests. EVIDENCE: The manager has considerable knowledge and experience of running a care service for older people. They had a good understanding of the conditions and illnesses that are associated with old age and was able to address such issues quickly, benefiting the residents. It was clear that the owner and manager had continued to work hard to improve the service. The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 22 The returned Annual Quality Assurance Assessment form recorded that all maintenance checks were up to date. Random samples of the gas certificate, servicing of lift and hoists and fire equipment were undertaken and found to be in order. The manager had started a supervision system and was working systematically through the staff team. All but the more recently recruited staff were said to have received supervision and some supervision notes were seen on the files inspected. The manager has showed a good understanding of the areas of weakness and there is a good capacity for the service to improve. Comments from staff about the management of the home included “things have really improved they are much better a much nicer place to work the manager is available 24/7 for advice” and “take concerns to manager”. Residents described the manager as “really lovely”, “very friendly”, “very nice indeed” and “spends a lot of time with us”. They also passed very positive comments about the owner and one resident said “he’s a good lad” and another said, “he looks after us very well”. A requirement is made that the manager makes an application for registration with the CSCI. All residents spoken with were happy with the arrangements regarding personal monies. The registered provider did not act as appointee for any residents. Where the home had involvement with residents’ monies, appropriate records and receipts were held. It is recommended that the home develop a formal agreement between residents or their representatives, that staff can access people’s personal monies to purchase personal items. The manager showed us a copy of the quality assurance questionnaire. This was called a ‘Stakeholder Survey’. Any responses were used to improve the quality of the service. A fire risk assessment was in place and this had been assessed by the local fire officer. The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 23 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X 3 X 3 3 X 2 The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 24 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 OP19 Regulation 13 (4) Requirement Risk assessments must be carried out in relation to the mobile heater and kettle in one resident’s bedroom. The broken bath panel on the first floor must be replaced. Star locks must be removed from bedroom doors. 2. OP29 19 (1)(a) Two written references must be obtained prior to new staff starting work at the home. The manager must make an application for registration with the CSCI. 31/07/08 Timescale for action 31/07/08 3. OP31 9 (1) 31/07/08 The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 25 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 OP14 Good Practice Recommendations Daily notes need to be reviewed to make sure that good quality useful information is being recorded. It is recommended that following a residents meeting they produce an action plan so that where residents raise issues they can see that action is being taken in response to their concerns/ideas. It was recommended that a record of the complaint, the investigation and the outcome be kept to keep an audit trail of how complaints are dealt with. It was strongly recommended residents be asked if they want a lock on the bedroom door. It is recommended that where proof of identity is copied for staff files the manager sign the photocopy to indicate that they have seen the original documents. It is recommended that the home’s policies, procedures and working practices be reviewed to reflect the implications of the Mental capacity Act 2005. It is recommended that the home develop a formal agreement between residents or their representatives, that staff can access people’s personal monies to purchase personal items. 3. OP16 4. 5. 6. 7. OP19 OP29 OP31 OP35 The Rosemary Care Home DS0000066311.V365676.R01.S.doc Version 5.2 Page 26 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. 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