Inspection on 31/05/05 for Three Roses

This inspection was carried out on 31st May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Three Roses 28/06/07

Three Roses 14/12/05

Three Roses 20/10/04

Three Roses 06/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Three Roses Bromsgrove Road Clent Stourbridge DY9 9QP Lead Inspector Rachel McGorman FINAL - Unannounced 31 May 2005 10:00 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Three Roses Address Bromsgrove Road Holy Cross Clent DY9 9QP 01562 730730 01562 730310 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Three Roses Homes Ltd. Mrs Isobel Bowen-Shaw CRH 14 Learning Disability 14 Category(ies) of LD registration, with number of places Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection 20 October 2004 Brief Description of the Service: Three Roses is registered to provide residential care for up to fourteen younger adults who have learning difficulties. The home is under the control of Three Roses Homes Ltd., a registered charity, which is run on the basis of a non-profit making company. The Board of Trustees have appointed three Directors, one of these being Mr Michael Noott, who acts as Company Secretary and also maintains regular oversight of the home. Mrs Isobel Bowen-Shaw, the registered care manager, has responsibility for the day-to-day running of the home. The fundamental philosophy underpinning the operation of the home was said to be an adaptation of the Rudolph Steiner approach to care and many of the existing resident group previously attended schools that had been run on Steiner principles. The premises have been developed and upgraded over the years to provide suitable and very pleasant accommodation. The building is single storey, and set in extensive grounds which border open countryside. The stated aim of Three Roses is to provide an environment which enhances the dignity, self respect and individuality of residents, where they are assisted to develop independence in self-care, domestic competence and daily living skills by ” Learning through Doing”. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to fulfil the statutory requirement and to monitor the care provision at the home in relation to the stated aims and objectives. The inspection took approximately 5 hours, and included joining the residents and staff for lunch. The majority of one inspector’s time was spent with service users, either in their rooms, or in the craft room and in the garden, while the other inspector spent time with the care manager, checking documentation and discussing the organisational arrangements. The care records of 3 residents were seen, and their life books were discussed with them in great detail. Discussions were held with 3 members of staff, and their files were inspected. A very favourable impression was gained about what it is like to work at Three Roses. The records kept in respect of the maintenance of equipment and safe working practices were checked during the inspection. What the service does well: Three Roses is a happy home, where a strong sense of community exists. Service users are considered to each have a valid contribution to make and are encouraged to express their personal beliefs, wishes and views. This ethos contributes to the development of the mutual respect and consideration evident amongst the group, and involves both residents and staff, and is also extended to inspectors. Comprehensive information is provided for residents, and good lines of communication ensure that everyone has the relevant information to enable appropriate decisions to be made about their daily lives. Staff members are flexible, and this approach enables them to respond to the changing needs of service users. Training opportunities are provided and each know they are valued. Recording procedures are maintained to a high standard, and confirm the good organisational ability of the management of the home. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 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. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 & 5 Appropriate documentation is in place to enable prospective service users to make an informed decision about their future care needs. The admissions procedure is followed in detail, and all proposed admissions to the home are planned very thoroughly, over several weeks, to ensure an appropriate decision is made, both by the home and the service user. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 9 EVIDENCE: A Statement of purpose has been produced, which together with the Service Users Guide provides detailed information for residents and their families, on which to base decisions about their future care needs. The documentation can be produced in an appropriate format if needed, and the Service Users Guide contained numerous photographs. The admission procedure includes extensive assessment by staff from the home, and a Community Care Assessment is undertaken by a social worker. Initially, this forms the basis of discussions regarding the suitability of the placement, and ultimately is used to develop a care plan for the service user. There have been no new admissions to Three Roses in recent months, although evidence of the way in which the admission procedures are implemented was found in the individual files of service users, and confirmed in discussions with the care manager. A planned introduction to the home is undertaken over a period of time, for all prospective service users, and a trial placement of up to six months is offered. The individual needs of each service user are identified in relation to the aims and objectives of the home and also the existing client group. A statement of terms and conditions of residence is provided for each service user. The details of these documents are discussed with each individual, and their family, and a signature obtained. A contract is also provided for each service user by the placing authority. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 & 9 The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. Service users at Three Roses are supported in making choices in all areas of their lives, and risk management strategies enabled a responsible approach to the risks associated with the various and numerous activities undertaken. The well-documented views of service users are central to the delivery of the person centred care that is provided at the home. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 11 EVIDENCE: An Individual plan of care is maintained for each service user, and these are regularly updated. The preferences of each person are also discussed, and residents are involved in planning every aspect of their day, with the support and encouragement of staff. A weekly diary sheet is posted in each bedroom, to remind them of their proposed activity for each day. Assessment is ongoing, with a monthly audit and skills assessment for each person. Multi-disciplinary team meetings are also called when additional intervention is needed. Reviews are held at least annually with the family, and any other relevant person. Discussions with the funding authority are being held in respect of one service user whose needs have increased, and reviews have been requested for three other residents. A key worker system is in place, and each service user has a ‘special friend’, who assists them to produce a ‘Life book’, which traces their personal history and is illustrated with numerous photographs. Several of these books were seen, and discussed with their respective authors, during the course of the inspection. The residents thoroughly enjoyed talking about the contents, which included their family, weddings they attended, the many interesting things they had done, and their achievements, holiday escapades, and events in their every day lives. Risk assessment is undertaken in relation to all aspects of the home. Service users are given regular instruction on fire safety awareness and are involved in the fire drills that are regularly organised. Assessment of the risks associated with the many activities undertaken by each resident was recorded. A copy was kept in the individual files of service users, and this was reviewed regularly. Three Roses is run as a ‘community’, and residents share the responsibilities of family group living, by helping in various tasks around the house. Everyone is involved in the planning and preparation of meals, although there is less involvement in the actual gardening now, as everyone is getting a little older, but less strenuous tasks are still tackled. Two residents were outside helping the gardener today. The food that is produced e.g. fruit and vegetables are picked, prepared, frozen or preserved, and then eaten by service users, staff and visitors. Discussions were held, after lunch about who was going to do certain tasks, such as wiping the tables and helping to dry the dishes, and several service users volunteered to do other small jobs. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15 & 17. Three Roses is a hive of activity with service users obviously enjoying, and gaining fulfilment from their busy lives. Each individual is involved in planning their activities, both within and outside the home, and everything they do is approached with enthusiasm. Service users are involved in the arrangements for assisting with the running of the home, which so obviously revolves around them. A choice of nutritious and wholesome meals are provided at the home. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 13 EVIDENCE: A programme of leisure, recreational and educational activities is compiled in discussion with individual service users, their families or an advocate, which take place both within the home and in the wider community. Spiritual support is given in-house, with prayers being said daily and grace at meal times, and some residents like to attend the local church with staff or with their family. Service users are encouraged to maintain and develop their skills and to achieve their potential in several areas. Within the home environment a wide range of crafts are available e.g. pottery, painting, weaving, sewing, rug making, floristry and glass painting. Residents are encouraged to make cards to mark birthdays, or special occasions, and the inspector is often given a handmade Christmas card. Residents were observed doing various handicrafts, including tapestry and rug making, and proudly discussed their work. Music lessons are provided for all service users, and singing and drama is also encouraged. A concert is quite regularly produced, and two service users attend a local drama group Most residents attend a local college every week during term-time, but no-one is currently in paid employment, although one person helps at a residential home. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 14 Service users are involved in the local community in various ways, and enjoy shopping, going to the cinema, visiting the library, going to the pub and eating out. A wide variety of experiences are provided, and their enthusiasm about the many things they do is delightful. In addition they use the local leisure centre, and enjoy swimming and tenpin bowling, and visits to various places of interest are also organised regularly, with the occasional trip to the theatre, to see the Ballet, a pantomime, or an Old Tyme Music Hall show. Individual and group holidays are organised and some service users regularly go abroad, while others have been to Devon and Wales recently. Visits to, and holidays with family are also arranged. Public transport is used occasionally, although this is not easily accessible due to the rural location of Three Roses. The Inspectors were pleased to able to sample lunch, which was of a very high standard, and some of the vegetables used at the home had been grown in the garden. A choice is always available, and a record is maintained of the food provided. Special diets can be provided, e.g. gluten free. The occasion was very social with a leisurely and relaxed atmosphere and was organised around the service users. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 & 20 Support and encouragement is provided to each service user, in order to promote independence in respect of their personal and healthcare needs. The health of service users is frequently monitored to ensure their needs are fully met, and staff are well supported and given advice by the primary health care team. Arrangements for the safe administration of medication are in place at the home. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 16 EVIDENCE: Service users needs in respect of personal care are minimal, and with one exception all are mobile without assistance. Residents are enabled to visit their GP, or the practice nurse, when appropriate, to seek medical treatment, or for advice. An annual health check is arranged for each person, at the local medical centre. Visits to the optician and chiropodist are organised regularly, and regular six monthly dental checks are undertaken. The Dental Hygienist is seen every 6 – 8 weeks, and frequent teeth cleaning is considered to be important, therefore encouraged for all service users. Audiology services are provided, and at present, four residents use hearing aids. Following a previous visit to the home by the Pharmacist Inspector, the medicines policy has been reviewed and updated. A new cabinet and cupboards for the storage of medication have been provided, together with a separate box for each service users medication. The Medication Administration Records are being completed to a satisfactory standard. There is minimal use of medication at the home, although several service users have been prescribed thyroxine. Regular blood tests are undertaken by the practice nurse, which should ensure the use of this medication is monitored appropriately. Records relating to medical care are maintained to a satisfactory standard. The Health Action Plan, which forms part of the national development framework for people with a learning disability, was discussed with the care manager, who intends to implement these for each service user. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22&23 A satisfactory complaints procedure is followed at the home, and service users are encouraged and enabled to express their views and opinions. The awareness of the management, together with the training provided for staff, ensures the protection of service users from all forms of abuse EVIDENCE: A clear procedure for the investigation of complaints has been produced and any issues identified by service users are dealt with immediately. Discussions have been held with service users and their families regarding the process and all complaints are recorded, although none had been received recently. The management of the home is able to demonstrate a clear understanding of the issues relating to abuse, and an appropriate procedure is in place. Training for all staff on the Protection of Vulnerable Adults (POVA) has been provided. There is minimal challenging behaviour demonstrated by service users at Three Roses. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27 & 28 The premises are very suitable for their purpose and are safe, comfortable and clean. The standard of the accommodation is excellent, and provides service users with an attractive and homely place to live. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 19 EVIDENCE: Three Roses has been improved over several years to provide a very pleasant environment for fourteen service users, which complies fully with the National Minimum Standards, and exceeds these in many respects. There is a planned programme for the maintenance of the building, which includes ongoing upgrading and redecoration, and recently has included the following: • New carpeting has been fitted • The exterior of the premises has been repainted • The fire detection board and smoke detectors have been replaced • An all weather conservatory has been built New chairs are to be purchased for the living room area, and the chairs currently in use, will be transferred to the conservatory. The greenhouses and large gardens are cultivated, and produce fruit and vegetables organically. Several large flowerpots around the grounds have been planted with bedding to provide a very pleasant environment. Three Roses looks well preserved and cared for. There are 14 single occupancy bedrooms, and the addition of en suite toilet facilities has provided excellent facilities for each service user. The rooms have all been personalised with items which residents have made, and take great pride in, and these include rugs, cushion covers, pictures and pottery. There are several communal areas within the home that could be used for a variety of purposes and include: • Craft room and adjacent kiln room • Living room for activities • Smaller sitting room • Dining room • Conservatory Bathing facilities have always been satisfactory, but with the increasing age of service users, and in anticipation of a reduction in mobility, two new, easy access baths have been provided. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 & 36 The home is staffed by an experienced and competent team, and additional staff have been employed to ensure that the increasing needs of some service users could be met more effectively. The recruitment policy and practices ensure that service users are supported and protected appropriately. The management support provided to staff enabled a clear understanding of their roles and responsibilities, and ensured the promotion of the aims and objectives of the home. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 21 EVIDENCE: There are clear lines of accountability within the management structure of the home. All staff are provided with a job description and information is given on various policies and procedures relating to their work. The Care Manager has also developed an assessment procedure in the form of a questionnaire that involved self-appraisal, with a view to raising the awareness of staff. Training for staff is the responsibility of the Care Manager, and is given a high degree of importance at Three Roses, which is reflected in the abilities and commitment of all staff employed at the home. A training programme is in place, which has enabled more than 50 of the staff team to gain the National Vocational Qualification Level 2 in Care. Two members of staff are currently undertaking Level 2, and five staff also achieved Level 3 in Care, with another carer working towards Level 3. These achievements are commendable. The rotas indicated that staffing levels were being maintained at a satisfactory level, and this enabled many planned activities to be undertaken with service users. The staffing establishment has been increased to provide a minimum of 3 staff throughout the waking day, and a part time administrator has also been appointed, which has relieved the Care Manager of some of the extensive paper work. Specialist staff are employed, on a sessional basis, to provide music lessons and eurythmy, a form of movement to music. A computer instructor is also employed. There are minimal staff changes and very limited use of agency staff at Three Roses. Staff responses were all very positive about Three Roses being a lovely place to work. A thorough recruitment and selection procedure is followed at the home, and induction and foundation training implemented in line with the Learning Disability Award Framework (LDAF). Staff at Three Roses are well supported by the Directors and the Care Manager, with obvious benefits to service users. Staff development procedures have been introduced with supervision sessions organised on a regular basis and an annual appraisal undertaken with each member of staff. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39 & 42 The management arrangements at Three Roses are satisfactory, and staff and service users benefit from the positive leadership they receive. Effective quality monitoring is in place, and the views of residents, their relatives, staff and other interested parties are sought and responded to appropriately. The health, safety and welfare of service users is promoted and protected in respect of all safe working practices. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 23 EVIDENCE: The Care Manager, Mrs Isobel Bowen-Shaw, has many years experience working with this client group. Initially training as a teacher, she obtained the Certificate of Education, specialising in mental handicap. She has completed the Registered Managers Award, and the updated Assessors Award. There is evidence of a clear sense of direction and strong leadership skills in the management approach within the home. The interaction between service users and staff, and the mutual respect that everyone showed to each other, was pleasing to observe. The individuality of each service user is recognised and the constant efforts of staff, to achieve the aims and objectives of the home, are commendable. Residents’ meetings are regularly held and service users are involved in making decisions about the many aspects of daily living. They share the responsibilities of family group living by helping each other with various tasks in and around the home. The group dynamics were fascinating to see. Under the guidance and supervision of staff, service users are listened to and their views are considered to be valid. Independence is promoted and service users are given genuine and informed choices. An annual development plan has been produced, and service users are involved in a monthly audit of the care they receive. Annual reviews are arranged with the family of each service user, who are also encouraged to be closely involved with the home. A format has been developed to undertake surveys of the views of both service users and their families, and a copy will be submitted to the Commission on completion. A comprehensive health and safety policy has been produced and staff are trained in safe working practices. The care manager has a working knowledge of the relevant legislation and appropriate risk assessments are undertaken. Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 4 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x x Standard No 11 12 13 14 15 16 17 3 4 3 3 3 x 4 Standard No 31 32 33 34 35 36 Score 3 3 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Three Roses Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 4 4 3 x x 3 x E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement There are no requirements following this inspection Timescale for action 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. 3. Refer to Standard 13 19 3 Good Practice Recommendations Consideration should be given to the possibility of service users being given the opportunity to vote in elections A Health Action Plan should be developed with each service user. A record should be maintained of the temperatures taken of residents bath water Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 26 Commission for Social Care Inspection John Comyn Drive Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Three Roses E52 S18490 Three Roses V223574 310505.doc Version 1.30 Page 27 - 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. 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