Inspection on 27/11/07 for Nelson Mandela House

This is the latest available inspection report for this service, carried out on 27th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Nelson Mandela House 04/10/05

Nelson Mandela House 20/06/05

Nelson Mandela House 01/12/04

Nelson Mandela House 03/06/04

Nelson Mandela House 30/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Nelson Mandela House Whitburn Close Pendeford Wolverhampton West Midlands WV9 5NJ Lead Inspector Rosalind Dennis Key Unannounced Inspection 27th November 2007 10:00 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 Nelson Mandela House DS0000035973.V351306.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. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nelson Mandela House Address Whitburn Close Pendeford Wolverhampton West Midlands WV9 5NJ 01902-553462 01902 553468 margaret.mattox@wolverhampton.gov.uk www.wolverhampton.gov.uk Wolverhampton City Council 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) vacant post Care Home 37 Category(ies) of Dementia (8), Mental disorder, excluding registration, with number learning disability or dementia (8), Old age, not of places falling within any other category (29) Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 50 years and above Kinver unit 8 residents category DE, MD only with no number division between categories 19th December 2006 Date of last inspection Brief Description of the Service: Nelson Mandela House is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of thirty-seven adults. The service is managed by Wolverhampton City Councils Social Services Department and Mr Brian O’Leary is the responsible individual. Mrs Margaret Maddox is currently managing the home and intends to apply to CSCI in the near future to commence the formal process of registration with CSCI to be the Registered Manager. Nelson Mandela House is divided into four separate units, each unit comprises of single bedrooms, bathroom, separate toilets, a lounge area and a kitchen/dining area. All bedrooms are single occupancy with wash hand basin, en-suite toilet facilities are not provided. A Day Care service, which is not inspected by CSCI, is also based at the home. Nelson Mandela House is located in the centre of Pendeford near Wolverhampton, next to a bus route and a supermarket, other shops, library and health centre are nearby. People can obtain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk. The local authority determines costs of the services and the fees charged are based on an individual financial assessment of need. Although registered with CSCI to provide care to people with dementia and mental health problems Nelson Mandela House is not currently providing this service. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by one inspector over a period of around 6 hours. All ‘key’ standards were assessed during the daythat is those areas of service delivery that are considered essential to the running of a care home. During the inspection, time was spent speaking with people living at the home and their visitors, speaking with staff, as well as looking at records and observing staff in their work. Comments and views were collated from people living at the home, staff on duty and visitors, and the content of these is reflected within the individual outcome groups in the report. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed-Nelson Mandela House returned their completed AQAA to CSCI within the given timescale. Information within this document demonstrates that the manager is focussed on achieving good outcomes for people living at the home, acknowledges the strengths and weaknesses within the service and is able to plan for improvement. The AQAA provided information to supplement the inspection process. The manager, Margaret Maddox was on duty for the duration of the inspection and the inspection found the home functioning well, with people living and staying at the home satisfied with the care they receive. What the service does well: The home has a committed staff group who communicate effectively with people and show kindness in their approaches. During the inspection, people living at the home were eager to share their views about Nelson Mandela House-comments included:- ‘carers are good’, carers are golden’ ‘everyone is helpful’. The home provides opportunity for people to comment on different aspects of the service such as through ‘residents meetings’ and ‘satisfaction questionnaires’. Staff assess and plan care to take account of peoples’ likes/dislikes and preferences. Staff recognise diversity and cultural needs. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 6 People can choose to participate in social activity and are encouraged to maintain contact with their family and friends. Meals within the home are good, menus provide choice and variety which take into account special dietary needs and personal preferences. What has improved since the last inspection? What they could do better: It is considered that the service is currently performing well and shortfalls in the home are few. One requirement made as a result of this inspection is for an application to be submitted to CSCI so that the formal registration process of the manager can commence. It was established through discussion with the manager and care staff that not all staff have received recent or specific training in the safeguarding of adults and the home needs to put training in place so that all staff are familiar with the process of recognising potential abuse and the formal referral process. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 7 The home needs to start monitoring the temperature of the medication storage room and take a daily minimum and maximum temperature of the medication fridge; this is to ensure that medication is stored at the correct temperature. The home needs to audit all areas accessible to people living at the home and where it is identified that the current door opening mechanism reduces the person’s access or the person prefers to have their bedroom door open, then advice should be sought from the local fire officer regarding a suitable door closure device. 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. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 8 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 Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good assessment and admission procedure and this ensures that the home is able to meet people’s needs. EVIDENCE: Three peoples care files were examined which shows that people admitted to Nelson Mandela House have their needs assessed prior to their admission. For people admitted direct from hospital into an ‘interim’ care bed, this assessment is usually carried out by a social worker and the information faxed through to the home. Staff at the home then obtain further information at the time of the person’s admission. People and their significant others are given opportunity to visit Nelson Mandela House prior to their admission although in the case of emergency admissions this is not always possible. Two people spoke of how their transfer Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 10 from hospital was an anxious time but that they were made to feel very welcome at Nelson Mandela House by staff at the home. The home’s statement of purpose is available in the reception area of the home along with an assortment of informative leaflets about different advocacy services. The statement of purpose was updated earlier this year and provides clear information about the home and the services offered. Although registered with CSCI to provide care to people with dementia and mental health problems Nelson Mandela House is not currently providing this service. A ‘themed’ inspection took place in December 2006 with a specific focus of looking at information provided to people at the time of admission-the visit found that people had not been provided with a copy of the service user’s guide, the guide was out of date and did not include information on fees. At this inspection it was established that the service user guide is in the process of being updated and could therefore not be reviewed at this inspection. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 11 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. The care planning process provides staff with the information they require to meet people’s needs, this will be further enhanced by the departments plan to implement a more person-centred approach to care. EVIDENCE: People who were spoken with during the inspection provided positive comments about the care they receive at Nelson Mandela House, comments included ‘carers are good’, carers are golden’ ‘everyone is helpful’. Staff were observed attending to people’s needs and requests promptly and with respect. Three care records were examined and these show that care plans are drawn up from the assessments and sufficient information was present on these records to show the care needed for these people. Care staff maintain detailed daily records which describe the care given and any problems which may have occurred –such as a person feeling unwell or admission to hospital following a Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 12 fall. The records show that staff communicate any changes with the person’s significant other and seek advice from healthcare professionals as needed. Senior staff described some of the problems, which can be faced when people are admitted to the home at short notice such as difficulties in arranging for GP involvement-staff dealt with a situation very well during the inspection when a person needed to see a doctor. New assessment, care planning and risk management documentation is due to be introduced –it is considered this should enhance the current systems in place, which is quite basic and provides little evidence to show the involvement of people and their significant others in the drawing up and reviews of their care plans. The self-assessment completed by the manager confirms that staff responsible for administering medication, have undertaken specific training to equip them with the skills for this role. Medication is stored in a designated room, however this room is also used by the hairdresser later in the week-this situation was discussed with the manager for action to be taken in line with the departments medication policy. Observation of Medication Administration Record (MAR) showed that the method used to record on these sheets was not consistent and thus could create an increased risk of inaccuracies occurring-the manager took to resolve this issue. The home records the temperature of the fridge used to store medication, however on occasions the temperature recorded was too low and a daily minimum/maximum temperature had not been taken. The manager was also advised to start monitoring and recording the temperature of the medication room. Nelson Mandela House DS0000035973.V351306.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. People who use the service can choose to participate in social activity and are encouraged to maintain contact with their family and friends. Menus provide choice and variety taking into account special dietary needs and personal preferences. EVIDENCE: A ‘Day Centre’ is provided on site for people to access if they wish-although most people spoken with said they prefer to stay within the units near to their bedrooms, chatting to people or ‘watching the world go by’. Two people spoke of how they enjoy quizzes and board games and that staff will assist them to access these activities. Entertainers visit the home and people spoke of how they enjoyed the recent ‘Halloween party’. Copies of minutes for ‘residents meetings’ shows that people are given opportunity to discuss different aspects of the service such as activities, entertainment and meals. One person had recently commented within a survey that there should be ‘more outings’ and the manager within the ‘selfassessment’ has recognised a need to ‘continue to review current activity Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 14 patterns’-this ongoing review is essential to ensure people are provided with social and recreational activities which meet their individual preferences. People confirmed that daily routines are flexible and the atmosphere throughout the day appeared relaxed with staff providing assistance as needed. Information on advocacy services is available on notice boards as well as a range of leaflets about supportive services for people from different cultural and ethnic backgrounds. Each unit has a lounge, dining area and kitchenette and staff were observed offering regular snacks and drinks to people throughout the day. The meal served at lunchtime was well-presented and people described meals within the home as good, confirming choices are offered at each meal. The home is able to cater for different diets and people’s cultural dietary needs are catered for. The service has recently been awarded a 4 star rating for very high standards of compliance with food safety legislation following a visit from the local Environmental Health Department. Nelson Mandela House DS0000035973.V351306.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 ensures that people have access to a clear complaints procedure, which enables concerns or complaints to be dealt with promptly and professionally. Appropriate procedures are in place to safeguard people from potential abuse however not all staff have received recent training in local procedures-this needs to be put in place so that all staff are familiar with the process of recognising potential abuse and the formal referral process. EVIDENCE: Leaflets informing people of Wolverhampton City Council’s corporate complaints & compliments policy and procedure were readily available in the reception area of the home, copies of this leaflet were also available in other languages. Managers are responsible for completing monthly returns for all complaints and compliments received, this process enables close auditing of any complaints and the action taken to address them-observation of this document shows that the home has not received any complaints for some time. CSCI have not received any recent complaints about the service. All people spoken with during the inspection confirmed they would feel comfortable in raising any concerns with either the manager or other staff at the home. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 16 It was established through discussion with the manager and care staff that some staff have received training in the safeguarding of adults, other staff either received this training some time ago or as ‘generalised’ training as part of their NVQ. The home needs to ensure that all staff have received training in adult protection/abuse awareness. Senior staff have recently attended awareness training on the Mental Capacity Act and information was available to show that some staff have attended training in the management of actual and potential aggression (MAPA). Nelson Mandela House DS0000035973.V351306.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 home provides people with an attractive and clean place to live and further planned re-decoration will continue to enhance the appearance of the home EVIDENCE: A random selection of bedrooms and communal areas were observed and these appeared clean and the décor satisfactory. People spoke about how they had been involved in choosing the wall coverings and carpets in their bedrooms and lounge areas. Since the last inspection the home has been enhanced through an ongoing programme of refurbishment and re-decorationone of the lounges was being decorated on the day of inspection. New wall coverings and the trimming of trees and shrubs outside of the home have helped to create a brighter living environment. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 18 Information provided by the manager shows that the home has recently been surveyed with regard to access under the Disability Discrimination Act and a ‘loop system’ has now been implemented to assist people who have a hearing impairment. The home is also looking to improving signage within the home to assist people with communication or memory related difficulties. Staff receive training in infection control and observations made at the time of inspection shows that staff put training into practice during everyday activitiesthe home was very clean and staff were seen using protective clothing appropriately. Nelson Mandela House DS0000035973.V351306.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 good. This judgement has been made using available evidence including a visit to this service. Training opportunities within the home are generally good which ensures that staff are appropriately skilled and competent to carry out the duties for which they are employed. The recruitment procedures adopted by the department are currently under review to ensure they are robust and fully safeguard service users. EVIDENCE: On the day of this inspection staffing levels were confirmed by the manager and other staff as being 6 care staff on duty in the morning, 6 care staff in the afternoon and 3 care staff at night (plus a manager on a ‘sleep in’ shift). During the day one carer is allocated on each unit and two ‘floating’ members are available to assist where there is most need, the manager is supernumerary. People who were spoken with during the inspection felt that there are usually enough staff on to meet their needs, staff also consider that these current levels are sufficient to meet people’s needs safely and promptly. It was established that staffing levels were reduced for a period of time in the summer, resulting in a reduction of one carer per shift, this is despite a requirement at the last inspection to increase staffing numbers. An anonymous concern regarding the reduction in staffing levels was received by CSCI in July Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 20 2007. It is pleasing that staffing levels have now been increased again to those described above as observations made at this inspection indicates that the current levels are appropriate for the dependency of the people accommodated, the layout of the home and the potential impact of admissions to the home later in the day and during the night. A review of how the local authority conducts pre-employment checks was made in July 2007-this identified shortfalls and a lack of consistency with recruitment processes. The provider has committed to improving recruitment and recording procedures. Information pertaining to recruitment checks is currently not held at the home and the manager confirmed that no new staff have been appointed for sometime–therefore this standard could not be fully assessed on this occasion. The manager confirmed within the self-assessment document that staff induction training meets the National Minimum Standards. Staff are provided with a range of training, which is ongoing and designed to meet the needs of people who use the service. Observation of the manager’s training plan for this year shows that individual training needs were identified at the start of the year and then training planned accordingly–discussion with the manager and staff confirms that the training plan has almost been achieved, with staff attending training in disability and equality, deaf awareness and person-centred planning, as well as safe working practice topics. In the past 12 months senior staff have received training in Dementia Care Mapping and management of actual and potential aggression (MAPA). Around 78 of care staff have attained NVQ Level 2 in care, with other staff in the process of studying for this qualification. Nelson Mandela House DS0000035973.V351306.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, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the skills and knowledge to lead the staff team and manage the home. The home monitors and reviews processes to ensure that people receive a range of quality services. EVIDENCE: The manager Margaret Maddox has worked at Nelson Mandela house for around 18 months and has considerable experience in managing social care services for older people, she has also attained a management qualification called the Registered Manager’s Award and is currently studying for NVQ level 4 in care. Mrs Maddox has demonstrated through leading and managing the Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 22 home that she has the necessary skills for this role. An application now needs to be submitted to CSCI to enable the formal registration process with CSCI to commence. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that needs to be filled in once a year by all providers. The manager completed the AQAA and returned it the commission within the timescale given. The information contained within the AQAA shows that the manager acknowledges the strengths and weaknesses within the service and is able to plan for improvement. People spoke of how they can comment on the home through ‘residents meetings’ and observation of the minutes shows that topics such as activities, entertainment and meals were discussed recently. The home has recently started to enhance its quality assurance process by offering all people who stay at the home opportunity to comment on various aspects of the service through ‘feedback’ questionnaires –it was discussed that when all the results are collated then it is good practice to publish them, so that people are regularly kept informed of the results, including the action taken to address any negative feedback. The responses seen showed that people are generally satisfied with the service they receive. It was positive to see all the thank you cards, and letters of appreciation, which have been received by the home. Observation of a selection of individual financial records demonstrates that the home has robust systems in place to safeguard people’s financial interests and regular audits are undertaken of financial records to confirm accuracy. The self-assessment provides information to confirm that the service has a full range of policies and procedures to promote and protect service users’ health and safety. During a tour of the home equipment appeared well maintained, however two people spoke of how door wedges had been removed on the day of inspection and one of these people spoke of how he likes to have his bedroom door open. It was discussed with the manager that if people prefer to have their bedroom doors open then advice should be sought from the local fire officer regarding a suitable door closure device. Observation of the fire safety log book shows that fire safety checks are up to date. Nelson Mandela House DS0000035973.V351306.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 X X 3 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 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Nelson Mandela House DS0000035973.V351306.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 OP31 Regulation 8 Requirement The manager must apply for registration with CSCI. This is to ensure compliance with the Care Standards Act 2000 Timescale for action 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP9 OP18 Good Practice Recommendations The temperature of the rooms used to store medication should be monitored and recorded. This is to ensure that medication is stored at the correct temperature A daily minimum and maximum temperature of the medication fridge should be maintained. This is to ensure that the temperature remains within 2 and 8 ºC. All staff should be provided with training in safeguarding adults to ensure they are familiar with the process of recognising potential abuse and the formal referral process. It is strongly recommended that an audit of all areas accessible to people living at the home is undertaken. Where it is identified that the current door opening mechanism reduces the person’s access or the person DS0000035973.V351306.R01.S.doc Version 5.2 Page 25 4 OP38 Nelson Mandela House prefers to have their bedroom door open, then advice should be sought from the local fire officer regarding a suitable door closure device. Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Shrewsbury Local Office Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nelson Mandela House DS0000035973.V351306.R01.S.doc Version 5.2 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. 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