Inspection on 16/04/09 for St Mungo`s

This is the latest available inspection report for this service, carried out on 16th April 2009.

CQC found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Mungo`s 06/04/06

St Mungo`s 12/09/05

St Mungo`s 11/04/05

St Mungo`s 02/11/04

St Mungo`s 20/04/04

Similar services:

Ashlong House

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Herbert Street

Stacey Street Nursing Home

Haven (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 St Mungo`s 2 Hilldrop Road Tufnell Park London N7 0JE Lead Inspector Pearlet Storrod Unannounced Inspection 16th April 2009 10:00 St Mungo`s DS0000020973.V374844.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. St Mungo`s DS0000020973.V374844.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 St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mungo`s Address 2 Hilldrop Road Tufnell Park London N7 0JE 020 7700 6402 020 7607 2235 roberts@mungos.org 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) St Mungo Community Association Limited Robert Dean Harvey Solway Care Home 29 Category(ies) of Past or present alcohol dependence (29), Mental registration, with number disorder, excluding learning disability or of places dementia (29), Mental Disorder, excluding learning disability or dementia - over 65 years of age (29), Physical disability (29) St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Home registered for men and women with needs relating to Alcohol dependency together with mental disorder, physical disability and/or old age. maximum of 29 beds within the above facility Date of last inspection 16th April 2007 Brief Description of the Service: 2 Hilldrop Road is a care home situated off Camden Road. The home provides care and support for 29 men aged 50 and over who have experienced homelessness combined with mental health issues and/or alcohol dependency. The home is owned and managed by the St Mungo Association.2 Hilldrop Road is a listed building, which was converted from a church in 1990. Staff support service users in developing harm minimisation programmes to help them to manage their drinking. The staff team also assist service users to access mental health services in the local community. The fees are currently £719.57 including all meals. St Mungo`s DS0000020973.V374844.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 inspection begun on 15 April 2009 and was completed on 15 May 2009. It took 11 hours. Time was spent talking with the manager, his deputy, a few staff members and some of the people who use the service. Examination of the records and scrutiny of some files held in respect to people who use the service and staff. I toured the building to ascertain that the requirements relating to maintenance, repairs and other matters outlined in the previous reports were appropriately addressed. To assist me with the inspection I used a sample of the information recorded in the surveys returned from people who use the service, of which there were four and five from staff. The information sent to us were positive and helpful. I also took into consideration information set out in the (AQAA) Annual Quality Assurance Assessment together with the views of people using the service with whom I spoke during the inspection process. What the service does well: The service supports people who use services to continue to live their lives as independently as possible. They are encouraged and supported to access appropriate activities including work experience where possible. There was evidence of mutual respect between the people using the service and staff. House meetings occur regularly and topics include activities including trips and outings, meals and such like. The meeting provides an opportunity for people living at the service to voice any concerns that they might have. A person using the service commented, “The food is well cooked”. Another person registered the “meals” provided as something that the home does well. The home is commended for encouraging feedback about the services offered and to make complaints and suggestions to improve the delivery of services. Another person said, homely if tablecloths were provided at mealtimes together with a jug of water on the tables . The dining tables are now covered with tablecloths and the homely appearance was noted. Positive information were feedback from staff and people using the service. A staff member praised the recent staff restructure and said, “The staffing restructure is a great improvement”. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 6 There is evidence of good relationships between staff and health professionals 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. St Mungo`s DS0000020973.V374844.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 St Mungo`s DS0000020973.V374844.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): 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. Prospective people who use services have their individual aspirations and needs fully assessed. EVIDENCE: This service has a clear referral and assessment process. Supporting evidence exist to suggest that people who use the service can be assured that a comprehensive assessments of needs will be undertaken to ensure that individual needs and aspirations can be met. Prospective people who use services are invited to visit the home with their care co-ordinator to view the home, meet the manager and to ascertain their individual needs, wishes, likes and dislikes by way of an interview. Trial visits occur and once the placement is agreed the individual is then issued a copy of the service users guide and licence agreement, which is signed by the person using the service and a member of staff. The information gathered is used to formulate a suppport plan for the individual. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 9 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): 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 support plans have improved and are more person centred. Risk management plans are harmonised with individuals’ assessments of needs. EVIDENCE: There is a clear care planning system in place. Care plans are amended according to changing needs. Care reviews occur regularly. Senior support care workers are designated key workers and are responsible for setting up and arranging in consultation with the individual person using the service, for other significant person, such as health professional, if appropriate, to attend. People who use the service set their goals in consultation with staff and progress of achievements and outcomes are measured and outlined in the action plans devised by staff. These action plans are discussed at weekly meetings, which staff refer to as map meetings. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 10 A number of people living at the service are placed there because of past or present alcohol problems associated with mental illness, age and or other related issues such as homelessness. People who use services are encouraged to make their own decisions and where appropriate, are asked to sign an agreement jointly with their key worker as a way forward to facilitate a recovery approach, which is the ethos used to support the people living at the service. The views and decision of individuals are sought throughout the review and action planning processes. Individuals’ identified needs work in harmony with the risk management plans and these include for example, all aspects of personal and social support such as life skills development and activities, mental health support, medication, finances and physical health. People who use services are encouraged to take risks and the risk management plans are reviewed simultaneously with the care reviews. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 11 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: 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 who use services are supported to maintain as much independence in their lives as is possible. The cultural needs of people using the service are considered and embraced. EVIDENCE: Life skills workers organise a range of social events both inside and outside of the home. Accordingly, people using the service access a range of leisure facilities. Events are arranged in house from time to time and holidays are organised for those who wish to travel to Ireland for example. The abilities of some people participating in community activities and life skills development continues to be compromised by some individual’s past and present lifestyles such as alcohol dependency, age and or issues surrounding their mental health. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 12 Some people using the service have lost contact with friends and family and do not wish to rekindle past relationships. People using the service are generally supported to maintain contacts with friends and families, according to the choice and wishes of individuals, which are supported and respected by support staff. The cultural needs of people using the service are recognised and embraced by staff. Themed meals and events are arranged according to the wishes of people using the service. Black History Month and St. Patrick’s Day are celebrated to meet individuals’ needs and interest. There are set times for meals. Some meals are appropriately stored for those individuals who do not wish to eat their meals at the times arranged by the home. The meals provided are now included as part of the weekly charge. I spoke with three people using the using all of whom reported that the quality of food provided was good. One person for example said, “The food is well cooked”. Another asserted that one thing that the home does well were the “meals”. The complaints record showed that an individual complained that the service would be more “homely if tablecloths were provided at mealtimes together with a jug of water on the tables”. Tablecloths were noted on each table on the inspection day. Examination of the weekly menus indicated the provision of a good variety of food. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 13 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): 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 who use services appear to be appropriately supported with their personal, mental and physical health needs. EVIDENCE: A staff restructure has taken place at this home, which now enables consistency and continuity in the delivery of personal care services. Discussion with the managers, evidence from information noted at the inspection and reflected in the (AQAA) Annual Quality Assurance Assessment is that the personal support needs of people using the service have increased. For example, as much as 12 people diagnosed with dementia, 10 people requires help with washing/bathing, 7 people has a physical disability and 11 people requires help, support or prompts to eat their meals. Eighteen people were admitted to hospital over the last year. The increasing and complex needs of people using the service is apparent and a person using the service recorded in his survey, “the place is now like a nursing home as it has a lot of old people who needs too much care and it makes my health deteriorate as the place was not like it is now. Its bad now.” St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 14 Physiotherapist and occupational therapist input occur as necessary and I observed from the files of an individual person who uses the service, an objection to using a wheelchair following an assessment undertaken by an occupational health assessor. This individual concerned cherishes his independence in going to collect his benefits and the use of a wheelchair compromises this. Though the person is in hospital currently, staff in the home should ascertain whether the occupational health therapist could assess the need of the individual to use an electric wheelchair. One person self medicates though the room of this individual has no lockable piece of furniture in which to secure his medication. Staff must provide a lockable facility in the room of this individual in to enable them to keep their medication and or to store other personal belonging also. The medication cabinets were neat and tidy with no build up of stock for disposal. The previous requirements made by the Commission’s pharmacist now meet compliance. Medication management was found to be in order. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 15 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): 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. Staff continues to listen to the views of people who use the service and systems are in place that offers protection from abuse, neglect and selfharm. EVIDENCE: The home continues to have appropriate systems in place that enables people who use service to make complaints should they wish to do so. Those spoken with had no complaints to make. People who use services are given the opportunity to raise issues of concern at the house meetings or at any other time. There were ten complaints noted from the complaints register, eight were upheld and all were noted to have recorded actions and outcomes. A complaints and suggestion box is available for people who use the service to voice their concerns independently and privately. There were no complaints outstanding to be addressed. The home has an Adult Protection procedure (including Whistle Blowing), which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets. Discussion with staff demonstrated awareness and understanding in respect to the protection of vulnerable adults. A whistle blowing policy and procedure is in place. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 16 The manager has attended training in respect to the Mental Capacity Act 2005 and the Deprivation of Liberty. He is in the process of registering some of his staff to attend such training with Islington Council. Monies held for people using the service appears to be appropriately managed and there is evidence that some individuals are under Court of Protection and or Appointeeship orders as necessary. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 17 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): 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. Some improvements have been made to enhance the environmental standards within the home. EVIDENCE: The home is as well designed as it can be, it was previously used as a church and the building is listed. Some improvements have been made to enhance the environmental standards within the home. A number of comfortable lounges are provided. Most areas of the building are disability accessible. Both the manager and his deputy confirmed that the carpet on the first floor landing was due for replacement in a short while. An individual commented that the home could do better if it, “remove all the dirty carpets as they smell.” I visited the home since the initial inspection date and noted that the carpet on the first floor landing had been removed and that landing fitted with new wooden flooring, which enhanced the appearance, St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 18 feel and odour within that area of the home. Still to be replaced are the carpets to the staircases and upper landing areas in the premises. The fire inspection report is dated 15/7/2008. A report in respect to the electric wiring is available and dated 28 November 2008. No requirements were noted from the report. A report from the Environment Health Standards Agency in December 2008 reflected the need for the ventilation system to be overhauled, particularly to the kitchen and bathroom areas. The overhauling of the ventilation system had started and is ongoing and staff asserted that an improvement has been noted to the ventilation system within the kitchen. A cockroach infestation was reported and a deep clean has occurred but this has not dealt with the problem. The provider’s dissatisfaction with the deep cleaning service was observed in written correspondences and the deep cleaning process is to be repeated until the eradication is successful. The water system is tested regularly for Legionella purposes. I had the benefit of seen the personal rooms of two people using the service by invitation. The rooms were orderly with walls painted in the colours chosen by the people residing in the rooms. I discussed with the manager and his deputy about the possibility of fitting tiles to some of the bedside tables in the rooms of people using the service, to prevent cigarette burns to the tables and to make cleaning easier when drinks are spilt. A large table has been purchased for the training room and throughout the house, appropriately hung up, are various paintings and drawings that demonstrate the work of some of the people using the service. Although significant improvements have been made to the physical standards of the home in a step by step way, the bathrooms that were upgraded within the last couple of years will need to be spring cleaned for example, grouting between the tiles needs to be cleaned to tackle the grime in these areas and enhance the cleanliness within the bathrooms and rooms housing the toilets. The home is generally clean but malodour is noted the communal areas that are carpeted. Battery operated air fresheners could also be fitted to the bathrooms and hall areas to present a pleasant aroma to these areas. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 19 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): 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. A trained and competent staff team supports people who use the service. EVIDENCE: Staff are appropriately qualified with relevant qualifications to work in care homes. They continue to demonstrate a caring attitude and commitment in the work that they do and they had a good understanding of their own and other’s roles and responsibilities, particularly since the restructuring occurred. Staff commented positively in respect to the staffing restructure recently undertaken. An individual said, “The staffing restructure is a great improvement”. Another person reflected, “More refresher training was needed”. The AQAA reflected that more staff are to attend refresher safeguarding adults training, possibly including courses provided by Islington. All newly recruited staff will receive safeguarding adults training as part of the induction process. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 20 Recruitment of more permanent staff is ongoing; a staff member mentioned the recruitment of more permanent staff as a necessity. Out of the 5 surveys returned from staff, everyone felt that the home works well in providing services to people with complex needs, some of who are challenging. I examined the paperwork contained in a sample of four staff files and the findings were that staff photographs were missing on each of the files that were inspected. Some files did not demonstrate that robust recruitment checks had been conducted. For example, the references were not properly verified by use of letter headed paper, rubber stamp or compliment slip attached. There was also no evidence of immigration clearance for work relating to an individual. The provider must ensure that thorough recruitment checks are carried out for all staff. All staff receives formal supervision on a monthly basis, though there was evidence of slippage noted previously and things appear to be back on an even keel. Staff appraisals occur. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 21 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): 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 home is generally managed well though some attention needs to be paid in some areas to ensure that people who use the service are continuously safe. EVIDENCE: The Care Manager has completed the NVQ Level 4 in Management and Care. He was the former deputy and his registration was approved on 14 January 2008. The Care Manager has a clear vision for the service and is clearly committed to working with this client group. Positive developments have taken place since his appointment and overall the home is managed well. Mutual respect between people using the service and staff were observed at all times. St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 22 There is evidence that both Manager and Deputy co-ordinate well as a team. Staff reported to the Inspector that they felt able to discuss any issues with the management group and considered that their contributions are valued. St Mungo’s has a quality department, which sends out anonymous surveys to all service users on an annual basis. This assists them to monitor the home’s progress and develop the yearly business plan. The home has a range of appropriate policies and procedures, which were seen by the Inspector in the quality manual and in the self-assessment tool. I observed from the AQAA dataset that some policies required updating. I revisited the home for clarification and supporting evidence. There was supporting evidence that some of the policies and procedures included in the quality manual did not correspond with the updated versions on the intranet. The deputy manager on duty gave an undertaking to ensure that the contents of the manual were updated in alignment with those on the provider’s intranet system. Regular monthly visits by the identified Responsible Individual were not occurring on a monthly basis. For example, no visits appeared to occur from 25 July 2008. The visits resumed in January 2009. Slippage occurred in February of this year and resumed again on 5 March and 23 April 2009 respectively. Slippage was observed in the self-assessment tool. The home continues to be well managed and a number of improvements have been made since the previous inspection visit. For example, the fire record demonstrates a lapse in the conduction of fire drills. The previous drill recorded occurred on 30/11/2007 and the 13/3/2009. Available staff were unable to show that other fire drills had occurred between the times indicated above. It was noted at this inspection and from the self-assessment tool that the fire evacuation plan is being reviewed. Regular health and safety checks are generally conducted such as testing of the alarm system. The service and maintenance records in respect to the lift, electrical wiring and the testing of small electrical appliances were sound. St Mungo`s DS0000020973.V374844.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 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 x 2 3 3 x 4 x 5 x 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 3 26 x 27 3 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 2 x 2 x Version 5.2 Page 24 St Mungo`s DS0000020973.V374844.R01.S.doc Yes 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 YA34 Regulation 19 Requirement Timescale for action 30/07/09 2. YA39 26 3. YA42 23 (4)(e) The registered manager must ensure that the references for all staff employed are properly verified. This would go toward ensuring that the people using the service are protected from harm 30/05/09 The registered person must ensure that they visit the home at least once each month Unannounced, and to inspect the home and the services provided and to prepare a report on the conduct of the home. Regular monitoring of the service would enable the provider to test the quality of the services that are offered and to ascertain whether the aims and objectives outlined in the statement of purpose are being met. The registered person must 30/07/09 ensure that fire drills are conducted at frequent intervals within the home to ensure the continuous safety and protection of people using the service and staff St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24YA30 Good Practice Recommendations The registered provider must continue with the general improvements being made. This includes the replacing the carpets in the communal areas that are in poor condition. They must also clean the tiles on the walls in the bathroom and the grout between the tiles. To ensure that the people using the service enjoy a home that is homely, pleasant and free of malodour The registered person should ensure that the home review their policy and procedure for promoting continence. They should also ensure that their policy manual is reviewed to ascertain that it includes current policies, procedures and codes of practice. 2. YA40 St Mungo`s DS0000020973.V374844.R01.S.doc Version 5.2 Page 26 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. St Mungo`s DS0000020973.V374844.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!