Inspection on 05/07/06 for 117 to 119 Mollands Lane

This inspection was carried out on 5th July 2006.

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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

117 to 119 Mollands Lane 13/12/05

117 to 119 Mollands Lane 14/06/05

117 to 119 Mollands Lane 24/02/05

117 to 119 Mollands Lane 29/11/04

117 to 119 Mollands Lane 29/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Mollands Lane (117/119) 117/119 Mollands Lane South Ockendon Essex RM15 6DJ Lead Inspector Mr Trevor Davey Key Unannounced Inspection 5th July 2006 10:35 Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 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 Mollands Lane (117/119) DS0000018058.V303110.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 Adults 18-65. 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. Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mollands Lane (117/119) Address 117/119 Mollands Lane South Ockendon Essex RM15 6DJ 01708 851963 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) 117-119mollandslane@east.ten.co.uk East Homes Limited Maurice Victor Finney Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Care to be provided to service users with a learning disability excluding mental disorder or dementia between the age of 18 - 65 years. Care to be provided to service users with a learning disability excluding mental disorder or dementia over the age of 65 years. Maximum number to be registered - 6 service users. Date of last inspection 13th December 2005 Brief Description of the Service: 117/119 Mollands Lane is registered to provide personal care and accommodation to six adults with a learning disability. Three of the current residents are elderly and the Registered Provider has submitted an application to vary the registration to admit elderly people with a learning disability, which has been approved. The homes accommodation includes six single bedrooms, which are situated on the first floor with two dining rooms and separate lounges on the ground floor. There are also two kitchens and corridors on the ground and first floors, link the two dwellings. There is no shaft lift in the home. The home has its own vehicle, which is regularly used to convey residents to shops and other amenities within the local community. There is good bus and train links to the area but not near to the home. Residents within the home are involved in a range of leisure, work and college activities. The property has an attractive landscaped garden at the rear and parking facilities are available to the front of the property. The monthly range of fees was not stated on the Pre- inspection questionnaire. Extra charges are made for hairdressing, chiropody, toiletries, holidays and meals out. Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit took place over a period of 7.00 hours. The visit mainly focused on the progress the home had made since last inspection and covered all key standards. A tour of the Home took place. Staff and residents were spoken with during the site visit who were helpful in their contributions and the assistance they gave to the Inspector. In addition, case tracking took place using some of the personal care records and other official records within the home were also assessed. Letters had been sent out to health care professionals and funding authorities requesting feedback of the service provided by the home. In addition, survey forms were also sent to relatives. From the responses received, these were generally positive and complimentary regarding the care provided. There were some concerns expressed regarding the lack of staff on occasions and the need for additional daytime activities, particularly in view of the recent closure of day-care services previously provided by Thurrock Social Services Department. This report also outlines new initiatives which have been taken by the home to increase social activities and opportunities in the community. Information was also taken from the pre-inspection questionnaire submitted by the manager. What the service does well: The home is able to demonstrate its effectiveness in communicating with residents who have a variety of needs, which are identified and clearly recorded in personal care records which are regularly reviewed. These records include individual diaries for residents which are regularly updated and include evidence of social contacts, activities and routines of the day as well as issues discussed with members of staff. The staff team have also been positive in engaging with residents to find new social and recreational opportunities in the area. These are proving to be popular with residents which include adult college placements and attendance at various social clubs. The home is also in the process of developing a more user-friendly survey/feedback form for residents. The increased use of pictures and symbols to assist in improving conversation with residents who have communication difficulties, is also used by the staff team. Good working relationships exist with other healthcare professionals which is evidenced in personal care records/plans and training protocols. Training records showed that relevant and specific topics of training had been completed by staff. Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mollands Lane (117/119) DS0000018058.V303110.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 Mollands Lane (117/119) DS0000018058.V303110.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The Statement of Purpose and Service User Guide omits specific information which residents and prospective users of the service require to enable them to make an informed choice about living in the home. Pre-admission assessment details for care/health needs were not available to give staff suitable information to determine whether the needs of potential residents could be met by the home. EVIDENCE: The current Statement of Purpose and Service User Guide does has not been updated to reflect the changes in the management structure of the home and the Responsible Individual. Currently there is no clear reference regarding the facilities provided in the home taking into account the long-term care needs of elderly residents and that there is no shaft left available to access the first floor. Any revision in the layout of these documents should be user-friendly and be presented in an appropriate format to take account of the needs of residents. From the sample check made, two of the residents who had been admitted to the home in October 2003 had no pre-assessment information available as to their identified needs and social history. The home is aware that for new residents, pre-admission assessments must be done. It is understood that both residents visited the home and had overnight stays prior to admission Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 9 which is part of the normal pre-admission process. process. Following admission, care plans and risk assessments had subsequently been drawn up. Mollands Lane (117/119) DS0000018058.V303110.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome in area is good. This judgment has been made using available evidence including a visit to this service. Care plans together with risk assessments, were in place which had been drawn up following discussion with residents, taking account of individual needs and showing how support is to be provided. EVIDENCE: Case tracking took place in respect of three residents which included an inspection of the personal care records as well as conversations with the residents concerned. Comments from residents were positive about life in the home and they confirmed that they were able to follow their own preferred daily routines in accordance with chosen individual lifestyles. Staff were said to be helpful and supportive in assisting residents with chores within the home including washing and meal preparation. Staff were observed to be engaged with residents which included accompanying them to shops, local markets and clubs within the local community. Some residents also attend college during the week. Individual diaries were being kept for each resident and entries recorded, confirmed the activities undertaken, involvement of staff and other social/family contacts. As well as care plans, risk assessments had been drawn up which included the safe use of wheelchairs, use of electrical equipment as well as the action and support to be provided by staff to minimise the risk of Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 11 falls. Care plans were comprehensive covering the holistic needs of residents including individual profiles, personal aspirations and health information. These also included objectives, implementation (where-what-who). Evidence was available to show that care plans had been evaluated monthly and the views of staff, residents and advocates (where appropriate), had been taken into account and recorded. Mollands Lane (117/119) DS0000018058.V303110.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 &17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home provides an activities/recreational programme in accordance with individual needs and choices which is linked into the local community. Residents are able to enjoy regular appropriate family and personal relationships. Residents rights are respected and daily responsibilities in the home encouraged. EVIDENCE: Conversations with residents confirmed that they were able to enjoy and take part in a variety of leisure and recreational activities. The Inspector was shown holiday books which included photographs of places visited and staff who had accompanied residents to provided support. Personal possessions in residents rooms, pictures and photographs reflected individual interests and hobbies. Residents also confirmed that the home had a flexible approach and there were no rigid times for rising in the morning or going to bed at night. The interaction of key workers was appreciated by residents and a good working relationship existed between them. Some of the activities attended included computer sessions as well as art and craft classes at the local adult education college as well as keep- fit and musical sessions. Since the closure Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 13 of day-care facilities which had previously been run by the local Social Services Department, the staff team have worked well with residents to find alternative daytime activities and residents spoken to were positive about their experiences. Staff spoken to talked about a new venture which is a Friday Club held in the local community hall where games and various activities are made available. Staff are also involving other residents from nearby care homes and hope this will expand. Personal care records and individual diaries contained evidence of leisure activities and other appointments attended by residents. Survey forms completed by families confirmed that relatives were always welcome into the home and that they were generally kept informed by staff of matters affecting residents. Some concern was expressed about the closure of some of the day centre facilities and the need for these to be compensated to ensure residents continue to enjoy a fulfilled social/recreational experiences. Some residents take the opportunity of visiting their families on a regular basis. Suitable transport arrangements are in place to convey residents on outings and to activities in the local community. A record was being maintained of dietary requirements likes and dislikes and discussions take place each week with residents which includes the aid of pictures/symbols in order to plan the weekly menu. Staff were observed asking residents what they would like for lunch and individual preferences were catered for. Some of the residents spoken to mentioned that they enjoyed particular favourite meals and that they were also offered a choice for breakfast. From conversation, observation and the inspection of records, there was evidence to show that the core values of rights, privacy, choice and independence were being upheld. Mollands Lane (117/119) DS0000018058.V303110.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Assessed and identified care/health and emotional needs were being met appropriately which included the added support of other health care professionals as required. Medication procedures were not always being maintained in accordance with Royal Pharmaceutical Society Guidance,which could place residents at risk. EVIDENCE: Some of the conversation with residents showed that they had a good awareness of their health care needs and how these were being met. Health information was clearly recorded in the care plan and included visits from the community nurse to change catheters, correspondence regarding cystoscopy appointments at hospital as well as visits to opticians and local doctors. Protocols were in place which had been drawn up by health care professionals showing the trained named staff who were able to carry out procedures. These protocols had also been reviewed periodically. Records of rectal diazepam which had been administered, were in place as well as emergency contact telephone numbers should these be required out of hours. Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 15 Local doctors involved with residents at the home have responded to the survey sent out by the CSCI to say that they have no cause for concern. Some of the residents are elderly and it is of some concern to the Inspector that bedroom accommodation is all situated on the first floor without the provision of a shaft lift enabling residents to have easy access. One of the residents commented that two people had visited the home to look at the possibility of installing a lift but this was not pursued. They would prefer the use of a ground floor bedroom if this could be made available. It was noted in the review placement notes of a funding authority for one resident which took place in September 2005, that because of increasing frailty, the resident may require a downstairs bedroom in the near future. It was further recommended that the placement should continue but that urgent consideration should be given to providing a downstairs bedroom. Risk assessments were in place which are regularly reviewed and some of the residents involved enjoy their independence and feel they are able to negotiate the stairs with little support from staff. (The Registered Provider should give urgent consideration to potential mobility problems and access to facilities in the home for older people, as specified under standard Y.A.29 Environment). One resident was able to tell the Inspector that since having a fall some time ago, a handrail had been fitted into the toilet. Confirmation was also given that staff empty catheter bags regularly and a call bell had been provided should additional staff assistance be required. Review information also included the views of key staff, residents as well as family and advocacy representatives when appropriate. Overall, the entries of care records were up-to-date although there were some omissions where baths had not been given in accordance with instructions laid down in the care plan. The home had provided risk assessments for the safe use of wheelchairs as well as supplying low -rise bed with mattress to minimise the risk of falls. A sample check was made of the medication administration records and some transcribing of prescription details had been written on to the record sheets and these had not been supported by two staff signatures or dated. Protocols for the administering of PRN (to be taken as required) medication were not available and when a course of medication had been completed, this had not always been shown or dated on the M.A.R. sheets. Any changes to prescription details must be confirmed in writing or by fax by the local doctors concerned. It is recommended that alternatively, when visiting the local surgery, the M.A.R. sheets for individual residents are taken for doctors to sign confirming any change in medication instructions. Mollands Lane (117/119) DS0000018058.V303110.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome in area was good. This judgment has been made using available evidence including a visit to this service. There is an established complaints procedure in place and residents views are listened to and acted upon. Staff have an understanding of the reporting procedure for the prevention of harm of vulnerable adults, ensuring that the safety of residents in the home is of paramount importance. EVIDENCE: The home has a complaints procedure which includes the use of symbols to assist residents with communication should they wish to take up issues. Residents spoken to were positive and confident with the way staff listened to their views and in the response received. Monthly meetings take place with residents and records are available in the home. One of the residents confirmed that they had been asked whether they were happy in the home and if there were any suggestions for improvement. No complaints had been received since the last inspection. Staff mentioned to the Inspector that a residents survey format is available but improvement work is taking place to make this more user-friendly. It is important for the views and suggestions of residents to be taken into account as well as consulting them when considering changes and improvements to the service. Staff have an awareness and have attended training on the prevention of harm to vulnerable adults and the reporting procedures necessary. Mollands Lane (117/119) DS0000018058.V303110.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,29 & 30 Quality in this outcome here is adequate. This judgment has been made using available evidence including a visit to this service. At the time of inspection, accommodation and facilities although of an acceptable standard, did not allow for easy access to the first-floor which increasingly diminishes the opportunity for the older residents to maximise their independence safely. The premises were being kept clean and hygienic and suitable laundry facilities were available. EVIDENCE: Overall, the premises were being maintained to ensure the safety of residents and facilities were kept clean and equipment serviced at regular intervals. Sample checks were made of hot water temperatures which were safe to the touch and a record of these was in place. A Health and Safety Report dated 1st. September 05 expressed concern regarding the blocking of air vents, the build up of condensation in the laundry room and other items. The Inspector was advised that these items have now been rectified. Fire precautions had been periodically checked and records were available. The last recorded portable appliance testing certificate was 18 May 2004 and there was no current electrical installation safety certificate available. Although risk assessments were in place and residents are assisted by staff, there is no shaft Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 18 lift to give older residents easy access to the first-floor bedroom accommodation. As residents get older and mobility problems become more apparent, safe access to the first-floor must be provided as well has sufficient space for bathing facilities and any mechanical lifting equipment which may be required to meet the need of individuals. Other communal areas and kitchens were ideally furnished and suited for the resident group, including the garden facilities. Mollands Lane (117/119) DS0000018058.V303110.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The number of staff on duty, with supporting supervision, was able to meet the needs of residents. It was not possible at this inspection to examine staff recruitment records. EVIDENCE: At the time of inspection, the manager was away on training and an acting manager was the person in charge for the day. A staff rota was available and there are normally two or three staff on duty which includes regular bank staff who are rostered and accompany/ support residents for various leisure activities, shopping and other appointments. There is always a trained member of staff on the premises who is trained to deal with any medical conditions which may arise where residents remain in the home. An awake member of staff is on duty during the night. Some of the responses from the survey forms returned to the CSCI, indicated that at times there were shortages of staff. This was not apparent on the day of inspection but the Registered Provider must ensure that at all times there are sufficient levels of staff, with appropriate supervision, to ensure the needs of residents are met. The Inspector was advised that the recruitment records were on the premises but only the permanent manager has access. These will be examined at the next inspection. Training records were available which included the names of staff who had completed a variety of courses including induction, prevention of Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 20 vulnerable adult training in 2005, moving and handling, medication administration, infection control and first aid. It was noted that none of the staff had completed training relating to the control of substances hazardous to health (C.O.S.H.H.) but it is understood that this is being planned. A number of staff had attended training on epilepsy awareness and one member staff had attended catheter care training. According to the pre-inspection questionnaire, 66 of the staff team have achieved NVQ level 2 or above. Mollands Lane (117/119) DS0000018058.V303110.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The registered manager is qualified and experienced to run the home to meet its stated purpose, aims and objectives. Systems are in place to ensure that the needs and views of residents are taken into account for improving the service. So far as reasonably practicable, the standards for health, safety and welfare of residents and staff are maintained. EVIDENCE: The manager has developed considerable experience over a number of years overseeing projects and managing homes which have involved people with a learning disability. The application for registration of this home, was approved in June 2006. Some tasks are delegated to other experienced members of the staff team. Regular interaction takes place between staff and residents and methods of communication are effective so as to ensure opportunities are always available for residents to raise concerns as well as expressing their wishes. From observation, comments received from residents and information Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 22 recorded on personal care plans, provision is made to meet individual needs and aspirations. As already mentioned under standard Y.A. 22 of this report, the management are developing their own questionnaire on a more userfriendly basis to enable residents to share their views about the service and any improvements which can be made. Regular monitoring visits are also made by the area manager and copies of reports are sent to the CSCI office. Protective surfaces/guards had been fitted to radiators and other servicing certificates were available for the premises and equipment. It was noted that the last portable appliance testing certificate was dated the 18th of May 2004 and this should be renewed on an annual basis. In addition, there was no current electrical installation/wiring safety certificate available which should be renewed every five years. The home was maintaining a daily record of fridge/freezer temperatures and it was noted that the freezer had a target for maintaining temperatures at minus 18° to minus 10°. Some of the recorded temperatures were shown as 21°, 22° and 24°. Appropriate adjustments should be made to ensure that temperatures are within limits. Regular dates had been recorded for fire drills and fire safety equipment checks. Mollands Lane (117/119) DS0000018058.V303110.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 2 2 2 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 x 26 x 27 x 28 x 29 2 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 x 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 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 6 Requirement The Registered Person shall keep under review and, where appropriate, revise the Statement of Purpose (in accordance with Schedule 1) and the Service User’s Guide. Copies of these documents must be sent to the Commission for Social Care Inspection as well as being made available to residents in the home. The Registered Person shall make arrangements for the recording, handling, safekeeping, and the administration and disposal of medicines received into the care home in accordance with the guidance issued by the Royal Pharmaceutical Society. The Registered Person must ensure that the premises are suitable for the purpose of achieving the aims and objectives set out in the Statement of Purpose. This includes the physical design and layout of the premises and providing suitable access to all parts of the building where the DS0000018058.V303110.R01.S.doc Timescale for action 30/09/06 2 YA20 13(2) 01/09/06 3 YA24 23 31/03/07 Mollands Lane (117/119) Version 5.2 Page 25 4 YA42 13(4) mobility of residents may be restricted. Standard Y.A.29 also applies. ( previous timescale of 30/06/06 not met). The Registered Person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable, free from hazards to their safety and any unnecessary risks to health or safety of service users are identified and so far is possible eliminated. This includes having current up –to-date servicing certificates for electrical wiring and installations as well as portable appliances. Safe storage temperatures must also be maintained and recorded for the refrigerator and freezer. 30/08/06 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 YA39 Good Practice Recommendations Feedback from residents should be sought and used as part of the continuous self-monitoring Process to improve services in the home. Mollands Lane (117/119) DS0000018058.V303110.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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