Care Home: Rosemary Residential Care Home

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What the care home does well The people consulted about the home said that they participate in review meetings convened by their care coordinator, they are encouraged to be more independent and there are opportunities for leisure activities. We were also told that staff respected their rights and they were treated with dignity, their complaints were taken seriously and they felt safe at the home.Rosemary Residential Care HomeDS0000026565.V377308.R01.S.docVersion 5.2 What has improved since the last inspection? Since the last inspection significant steps have been taken to improve the standards of care provided. The eight requirements from the last and previous inspection were met and people have made positive comments about the 1:1 time and activities that provided. What the care home could do better: There are two requirements arising from this inspection and relate to the further development of medication systems and risk assessments. A running balance of homely remedies must be maintained to ensure that staff can check that these medicines have been used appropriately. A record of medications no longer required must be maintained to ensure safe handling of medicines. Fire risk assessments action plan that draws together the findings from each room must be devised. This plan must state fire safety checks and the practices that will take place to ensure staff know the procedure to follow in the event of fire. Key inspection report CARE HOME ADULTS 18-65 Rosemary Residential Care Home Rosemary Residential Care Home 2 Guinea Lane Fishponds Bristol BS16 2HB Lead Inspector Sandra Jones Key Unannounced Inspection 11 & 12th August 2009 09:00 th Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosemary Residential Care Home Address Rosemary Residential Care Home 2 Guinea Lane Fishponds Bristol BS16 2HB 0117 9584190 0117 9020515 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Regina Odeh Mrs Regina Odeh Care Home 10 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (8), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (1) Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 8 persons with mental disorder aged 19 - 64 years May accommodate up to 1 person with a learning disability aged 50 years and over May accommodate up to 1 person with mental disorder aged 65 years and over 29th August 2008 Date of last inspection Brief Description of the Service: Rosemary is situated off Fishponds Road close to shops, places of worship and parks. Originally, the property was two domestic dwellings, converted to provide accommodation to ten people with mental health care needs. The home blends well with its local environment. It is operated by Mrs R. Odeh and registered to accommodate nine adults and one person over 65 years. Rosemary Residential Care Home DS0000026565.V377308.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 2 star. This means the people who use this service experience good quality outcomes. This key inspection was conducted unannounced over two days in August 2009 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection including the Annual Quality Assurance Assessment (AQAA). This information was used to plan the inspection visit. There are seven individuals living at the home and four were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the people living at the home and staff were gathered through face-to-face discussions. What the service does well: The people consulted about the home said that they participate in review meetings convened by their care coordinator, they are encouraged to be more independent and there are opportunities for leisure activities. We were also told that staff respected their rights and they were treated with dignity, their complaints were taken seriously and they felt safe at the home. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (1), (2) & (5). People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can decide whether the care home can meet their support and accommodation needs. This is because the person, their relatives and placing agencies have accurate information. The Statement of Purpose and Service User Guide needs to be reviewed so that people have up to date information about they home. EVIDENCE: The current group of people accommodated have lived together at the home since before the last inspection. There are eight people accommodated and there are vacancies for two people. There is an information pack that contains the home’s Statement of Purpose and Service User Guide, appropriate policies and procedures and a copy of the most recent CQC report. The stated aims of the home are to enable people to continue their lifestyle which is achieved by encouraging and working with Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 9 people to integrate in the community and participate in activities. The Service User Guide is clear about the way the care is to be delivered at the home. However, the expectations and rules of the home are not listed. People at the home must have detailed information about the home so that they make choices about moving into the home. The policy for admission is described and confirms a commitment to ensuring that people have enough information to make decisions about living at the home. The admission procedure must be reviewed to make clear the steps that will be taken to assess that the person meets the criteria for admission to the home. This will ensure that the skills of the staff can meet the needs of the people wishing to live at the home. Introductory visits and trial periods are offered to make certain that the person is suitable to live at the home. There is a home’s contract which informs people about the facilities and services offered at the home. The name of the individual, the fees charged and the room number are added to make the contract personal to the person. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (6), (7) & (9) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at the home have personalised care, they are involved in planning the way their care is delivered and are able to make decisions about their daily living. EVIDENCE: The case files of four people were examined and copies of Individuals Care Programme Approach (ICPA) plans, home’s care plans, risk assessments and monitoring form the care planning process of the home. ICPA’s meetings are annual and convened by the care coordinator, with the person present, social and health care professionals involved in the care Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 11 invited to the meetings. It is evident that from the ICPA’s, home’s care plans are developed which are monitored to assess the progress of the care plan. Where risks are identified, risk assessments are completed to ensure where possible the level of risk is reduced and the person can safely take risks. Care plans examined are personalised where the individual’s likes, dislikes and preferred routines are included. Showing that people have input into the way their care is to be delivered. Overall care plans are detailed and guide the staff to meet the needs in the way the person stipulates. Each month staff will review the care plan to assess the progress made with the action plan. Three people were consulted about the care planning arrangements at the home. Two people said that they attended ICPA meetings to discuss their care needs and they are able to make decisions about all aspects of their life. Staff explained that care planning is person centred and they discuss the care plans with the person every month when it is monitored. Risk assessments are completed for activities that may involve an element of risk. A management plan is then developed for each risk identified on the actions necessary to lower the level of risk. Where people exhibit aggressive and violent or inappropriate behaviours, the triggers are listed and the actions to be taken specified. While the action plans guide staff, the diffusion and diversion to be used must be added so that staff can consistently use techniques that are effective. The people accommodate have the capacity to verbally make decisions. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: (12), (13), (14), (16) & (17) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at the home are supported to pursue their chosen lifestyles and are part of the local community. They are better connected with their community and have opportunities for social and leisure activities. EVIDENCE: Individual’s social, educational and occupational needs are discussed during Individuals Care Programme Approach (ICPA) meetings. People at the home have little interest in educational and occupation opportunities as stated in their ICPA and their needs stated through the home’s care plan mainly focus on budgeting, shopping and independent living. Care planning review records show that people need encouragement to participate in these activities. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 13 The deputy manager said that three people attend the ‘I am one’ drop in centre operated by the Local Authority and generally people go on day trips organised by the drop in centre. 1:1 time is organised with individuals at the home, however, this is not routinely organised for everyone at the home. Cinema nights occur on Saturday nights with staff while others go out to the shops and restaurants with healthcare professionals involved in their care. People at the home are able to leave the home without staff support and are able to access the community independently. Comments from two staff on duty were sought about the opportunities available to people for social and leisure activities. We were told that people at the home are supported on shopping trips, 1:1 and cinema trips and are encouraged to become more independent. For example, doing their laundry and tidying their bedrooms. Three people at the home were then asked about the way the home responds to their social, educational and leisure needs. The three people consulted described their daily routines which included watching the television, visiting the shops and going to Cafes. People confirmed that staff support them with personal development and are encouraged to maintain their personal space clean. The home recognises the importance of maintaining links with friends and family, which is confirmed through the Visitors policy, visiting is open at the home. People said that their family and friends are welcome and they can have visitors in bedrooms for additional privacy. The rights of the people at the home are clearly stated in the Statement of Purpose and described is the way their rights including the Rights and Dignity policy are to be respected. People explained the ways staff respected their rights, we were told that staff knock on bedroom doors before entering, mail is handed unopened and they are not structured rules to retire and rise. Menus were revised since the last inspection and records show that a healthier diet that has fresh vegetables is served. Breakfast is generally continental style; there is a cooked meal at lunchtime and a lighter meal at tea time. Meal preparation was discussed with the staff, and they told us that people are asked about the menus and cultural meals are served. People said that they meals are good, alternatives are served and there is enough to eat. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (18), (19) & (20) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support from staff in the way they prefer and want. Health needs and are met and where necessary staff administer medicine in a safe way. EVIDENCE: With the exception of one, the people at the home are able to manage their own personal hygiene. Where people have personal care needs, the care plans specify the way their care is to be delivered. The contact details of the health and social care professionals involved are recorded within the individual’s file. People are registered with a local GP, Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 15 access NHS facilities and input from Psychiatrists and records show that people visit the GP; have annual health checks and check-ups at the optician and dentist. There is documentation in place supports that psychiatrists are involved through Individual Care Programme Approach (ICPA) meetings. Members of staff then record outcomes of visits from health care professionals which staff said ensures that medical advice it followed at the home. The staff also described the arrangements for healthcare at the home and we were told that people are accompanied on GP’s visit, health checks are six monthly and social workers and Community Psychiatric Nurses (CPN) are involved in the care of the people at the home. Three individuals confirmed these arrangements and two said they needed support visiting healthcare professional while one person said they were able to visit their GP independently. Medications are administered through a monitored dosage system and records examined were found to correspond with the medications held. Where medications are not administered, codes are used to explain the reasons for not administering the medication. Homely remedies for example, paracetamol are administered from a stock supply and a running balance of the medication must be kept. This will ensure that staff can check that these medicines have been used appropriately. A protocol for administering Paracetamols must be devised to ensure the safe use of homely remedies. Medication no longer required is returned to the chemist and while it’s acknowledged that returned medication is the monitored dosage system, a record of medications returned must be maintained. A record of medications returned must be maintained with the signature of the pharmacist to evidence receipt of the medication for disposal. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (22) & (23). People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffs respond to individuals concerns and complaints and are safeguarded from abuse. EVIDENCE: The Complaints procedure is specified within the Statement of Purpose and Service User Guide and makes clear the ethos of the home which is to learn, adopt and improve standards from the feedback received. Additionally specified is that complainants will be told of the actions to be taken to resolve the complaints, with the names of the agencies that can be contacted for unresolved complaints. Since the last inspection people made 7 complaints about each other and the record shows that the actions taken by the staff resolved the complaints satisfactorily. The WhistleBlowing and Safeguarding Adults policy in place show a commitment towards protecting people from abuse. The WhistleBlowing policy specifies that to create a culture of openness, staff that come forward and report poor practice will be protected from reprisals. It also states that staff that do not report poor practice may be subject to disciplinary procedures. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 17 The Safeguarding Adults procedure defines the factors of abuse and the actions to be taken for alleged abuse. Assurances that the home lessons learnt from any incident will be used to improve standards at the home are incorporated into the procedure. Members of staff told us that Safeguarding Adults refresher training was provided recently and they are aware of the steps to be taken to protect people from abuse. The people consulted said that staff would ‘sort out’ their complaints and they felt safe. Additional comments made included ‘I feel safe and no one shouts here’ and ‘I am treated much better here, I am not bullied by the provider and no one shouts.’ Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (24) & (30) People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home continues to redecorate to property so that people can live in a homely environment. EVIDENCE: Rosemary care home is situated off the Fishponds Rd. close to shops, places of worship and parks. Originally, the property was two separate domestic dwellings converted to provide accommodation to ten adults with mental health care needs. The property retains its domestic appearance, blending with its immediate environment. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 19 There is an extensive refurbishment programme in place and during the visit flooring was being replaced in bedrooms and people were given the choice of colours. Two bedrooms were also redecorated and corridor flooring was replaced. Shared space consists of a lounge and two dining rooms, one of which is used as a smoking area by people at the home. The laundry room is adjacent to the kitchen; it has a tiled floor and walls for easy cleaning. The washing machine and tumble dryer are domestic in size and recently replaced. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (32), (33), (34), (35) & (36) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. EVIDENCE: Application forms were amended to request the names of two references and the formal request for reference letter from the home requests that it be validated. Completed application forms, written references and Criminal Records Bureau (CRB) obtained are held in the personnel files of the people employed at the home. The training records show that the assistant managers’ have completed NVQ level 4 and RMA, two staff have NVQ level 2 and three are working towards NVQ level 2 and above. This shows that people are care by staff that are qualified to meet the needs of the people accommodated at the home. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 21 Since the last inspection Equalities, refresher Safeguarding Adults training, Effective Recording, Mental Capacity Acts and Deprivation of Liberty Safeguards was attended by the staff. Working with Learning Disabilities and Mental Health training was also attended to ensure the staff at the home are able to meet the changing needs of the people living at the home. The rota in place shows that the service provider, two assistant managers and support staff work 9:00 am – 8:00 pm each day. Ancillary staff for cooking and cleaning are also employed and at night one person sleeps in the premises. With the exception of two, staff have individual supervision with the assistant managers. Personal development is discussed and staff have to report on the actions to be taken as a result of the training attended. Comments were sought from staff about training and supervision and we were told supervision occurs eight weekly and there is access and support from the assistant manager with training. People consulted told us that the staff knew how to meet their needs. Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): (37), (39) & (42) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at the home can be reassured that standards are subject to ongoing monitoring and the property is safe for people living and working at the home. EVIDENCE: The direction of the home was discussed with the Assistant Manager who told us that the aim was to introduce an effective Quality Assurance (Q/A) system and improve the rating of the home. In terms of the Q.A. system the assistant manager said it will offer consistency and leadership is provided by the service Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 23 provider and two assistant managers’. The assistant manager then described the way consistency is maintained at the home. It was stated that individual’s supervision, staff meetings and handovers when shift changes occur ensure consistency of care at the home. Members of staff confirmed that supervision was taking place and that handovers which provide enough information to meet the needs of the people at the home. We were also told that the managers’ were approachable and suggestions made were taken seriously. People at the home told us they were well care for and the managers’ were approachable. A Quality Assurance system was introduced since the last inspection, questionnaires based on food, delivery of care, daily living, premises and management. Stakeholder questionnaires to professionals, friends and family will follow with an audit that covers all NMS standards will be completed by the assistant manage and the audit will summarise key elements to develop an improvement plan. Fire Risk assessments were undertaken in each room and preventative measures were identified for each room. An action plan that draws together the findings from each room must be devised. This plan must state fire safety checks and the practices that will take place to ensure staff know the procedure to follow in the event of fire. The service provider ensures that the home complies with associated legislation which includes annual checks of the boiler and portable electrical equipment. Rosemary Residential Care Home DS0000026565.V377308.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x Version 5.2 Page 25 Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement a) A record of medications no longer required at the home must be maintained and b) A running balance of homely remedies must be maintained to ensure safe administration of medications An action plan must be drawn together following the fire risk assessments to ensure that preventative measures are taken to reduce the potential of fire. Timescale for action 30/10/09 2 YA42 23 30/10/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosemary Residential Care Home DS0000026565.V377308.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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