Inspection on 06/11/06 for 23 Mount Pleasant

This inspection was carried out on 6th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

23 Mount Pleasant 08/06/07

23 Mount Pleasant 10/11/05

23 Mount Pleasant 13/07/05

23 Mount Pleasant 15/10/04

23 Mount Pleasant 04/06/04

23 Mount Pleasant 05/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 23 Mount Pleasant, Chesterton Newcastle Staffordshire ST5 7LH Lead Inspector Mr Berwyn Babb Key Unannounced Inspection 6 November 2006 15:00 23 Mount Pleasant, DS0000004983.V317031.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 23 Mount Pleasant, DS0000004983.V317031.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. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 23 Mount Pleasant, Address Chesterton Newcastle Staffordshire ST5 7LH 01782 565437 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) mntpleasant@choiceshousing.co.uk Choices Housing Association Limited Ms Susannah Jane Chard Care Home 8 Category(ies) of Learning disability (8), Physical disability (4) registration, with number of places 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10 November 2005 Brief Description of the Service: 23, Mount Pleasant is registered to provide care for eight Adults with a learning disability, four of whom may have a physical disability. This is one of a group of homes managed by the Choices Housing Association that is based in North Staffs. It is situated in the midst of local residential properties, close to shops and other neighbourhood facilities. It is not distinguished by signs or other means as a care home, and is in keeping with other adjacent properties. This accommodation is purpose built and situated on two levels. Each level provides a self-contained unit, which accommodates four service users. Access between the two floors is via a staircase. The ground floor comprises of four single bedrooms, spacious lounge, spacious kitchen/diner, assisted bathroom, separate toilet and laundry. The first floor comprises of four single bedrooms, spacious lounge, spacious kitchen/diner, assisted bathroom, separate toilet and an office, which also serves as the staff sleep-in room with en-suite facilities. The grounds are compact but well maintained, with a private and enclosed patio area to the rear accessible to all service users. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection was carried out during the late afternoon and evening of Monday the 6 November 2006 and the mid-morning of Tuesday 7 November 2006. From information given in a provided dataset sent to the commission prior to the inspection, it was established that the current rate of fees charged in this home range from £870 to £890 per week. For the majority of the inspection the Care Manager was on duty and afforded helpful assistance and hospitality. As well as observations made during the two visits to the home, this report include comments and views made by residents and staff, and information from Have your say feedback questionnaires, and comments cards received from relatives and one professional. Time was taken on the Monday to talk with the manager of the Day Service provision used by the home, and her comments have also been included. The home was clean and warm, and vibrant with activity, with residents coming and going to and from expeditions into the community, returning from Day Services, and moving around the home between areas and activities and association time with other residents. It was explained the residents with a greater degree of disability and who are unable to mobilise on their own live on the ground floor, whilst those living on the first floor are more independent, receiving monitoring, and support and guidance, rather than physical intervention by staff to ensure that their care needs are met. What the service does well: What has improved since the last inspection? Since the last inspection much work has taken place in the bathroom on the ground floor, including the fitting of a new hydraulically operated and lifting bath. This incorporates a Jacuzzi, spa, and hair washing facilities as part of its initial construction. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 6 The rolling programme of maintenance and redecoration continues, in both the bedrooms, and the lounges. New furniture has been provided in the lounges. 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. The summary of this inspection report can be made available in other formats on request. 23 Mount Pleasant, DS0000004983.V317031.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 23 Mount Pleasant, DS0000004983.V317031.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous inspection report indicated a review of both the statement of purpose and service users guide. Both documents have now been received at the CSCI office, and the service users guide had been suitably amended to incorporate picture symbols to enable people with communication difficulties greater opportunity to understand its contents. During the inspection the manager stated that even greater changes are being implemented to ensure that each document is so updated in line with the individual abilities of the residents, some of whom use one form of communication aid, and some of whom use another. Examination of the documents in the care plan of one resident who had been admitted most recently indicated that a full care management assessment had taken place prior to the admission to ensure that the home was suitable for the needs and choices of the resident, and be able to provide the care to meet those needs and personal choices. Based on this, a day-to-day care plan had been developed, and there were dates and signatures recording the times at which this had been reviewed, and any changes that had become necessary due to change in circumstances. 23 Mount Pleasant, DS0000004983.V317031.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality for this group of residents, in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents had extensive persons centred care plans, and these demonstrated the necessary input to allow them to take risks, and to fulfil those decisions that they had taken about their lives. EVIDENCE: A selection of care plans was read. These showed that residents were involved in decisions taken affecting how their individual needs and choices were met. One care plan was examined in minute detail and this demonstrated that it had been based on a single Care Management Assessment generated prior to his admission, and taking account of any risks that had been identified in a positive manner, with protocols put in place to ensure that he was able to meet his choices, if necessary with the input of training, advice, support, and staff monitoring. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 10 Agreed interventions were detailed to deal with expected or arising behavioural problems, and the resident key worker had insured that the plan was reviewed at appropriate intervals. There was a full health and safety assessment identifying what risks were acceptable and measures taken to reduce these, together with a bathing policy that went into the detail of the residents choice, dignity, and freedom to have a soak in line with his stated individual likes and dislikes. Because there had been concerns about the weight of this individual, there was a section on monitoring his body mass, in line with input and advice from the dietician. 23 Mount Pleasant, DS0000004983.V317031.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): 12, 13, 15, 16, and 17. Quality in this outcome area for this group of residents was good. This judgement has been made using available evidence including a visit to this service. Residents were seen to be taking part in activities that suited their age and their choice, to have good links with the local community, to retain contact with relatives and friends, to be treated with dignity in the home, especially in the promotion of their independence, and be enjoying nutritious and attractive meals that balanced a healthy diet for their assessed needs, with their individual choice of favourite foods. EVIDENCE: One resident found sheltered employment with the choices handy care team. Another resident attends college one day a week. In addition to this two of the residents go out to specialist day-care services each weekday. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 12 One man regularly attends an art and drama group. He was pleased to talk about plans that had been made for him to attend a concert just before Christmas, and he has involvement in a partnership programs being run by a local advocacy organisation, for whom he acts as a link into the meetings of residents that take place in the home. He is able to spend most of his weekends with his family, and was one of three people in the home who would be joining their families for Christmas. The care manager stated that all residents had contact with members of their family every week, and that they worked in partnership with Day Services to ensure that we are residents had the most integrated care into the community that it was possible to provide for them. By chance, the manager of their nearest Day Service provision came to the home during the inspection in order to take part in the multidisciplinary review of one of the residents. She took time to speak to the inspector and said that she had always found in her contacts with the home that staff were totally professional, and always eager to share and participate in the holistic planning for each individual. During the tour of inspection, privacy locks were observed on the doors of those people who were able to operate these, understand their significance, and desire their provision. There was evidence of involvement of the dietician both to assist people to maintain body mass, and also to reduce it. In discussion with the Care Manager, it was established that menus were not pre-planned so that they could take account of any changes in the provision of mid-day meals at Day Services, and respond to these by providing a suitable meal to fit in with that individuals overall eating programme. Another reason quoted for providing meals on an ad hoc basis within the boundaries of what was available, was the known behaviour of two residents who had a well-documented history of changing their mind about what it was they wanted to eat. She said that what the home actually does was to record what was actually eaten on the day. When this was examined, it was shown to cover a good variety of substantial meals, and to indicate where a build up supplements had been used to try and increase body mass, or because of difficulty in swallowing. Some residents were also benefiting from having their food cut up or liquidised, and the file also recorded the input of healthy eating and lighter meals aimed at helping an individual to reduce weight. 23 Mount Pleasant, DS0000004983.V317031.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, and 20. Quality in this outcome area was good. This judgment was arrived at using all the evidence available including a visit to the service, and was formed because residents were seen to receive comprehensive social and Healthcare support in line with their assessed needs and choices, and their programs had been reviewed regularly as demonstrated by the record in their personal care profiles. EVIDENCE: This service is specifically for people who have a learning disability, and in addition for of the current residents have physical disabilities that require the input of staff to assist them in their personal care. Those people who do not require direct assistance in washing and bathing benefit from close monitoring, and seven people will benefit from some form of assistance whilst taking their meals. Two of the residents have a hearing impairment and in total four people have limited verbal communication skills, and six people have impaired vision. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 14 Two residents supplement their verbal communication by using Makaton and British sign language, and documents examined during this inspection had been amended to make them more readily available to the individual with challenged communication skills. A member of staff who was engaged in a formal interview gave a detailed synopsis of how she would bathe a resident, and her description fulfilled the desired attitudes towards privacy, dignity, choice, and ensuring that the person was enabled by the process, rather than being disable by it. She took steps to ensure that health and safety were observed, as well as carrying out procedures to maximise infection control. From a sample care plan that was examined in detail, it was concluded that there was very thorough attention to the health care needs of the resident. This male resident had benefited from the annual Well Man Assessment in addition to input from his consultant psychiatrist, specialists in speech and language, the dietician, his GP, and domiciliary mental health and general nurses. Appointments to attend hospital, clinic, or GP surgery, had been made for him, and he had been assisted to attend to these. The tertiary Healthcare needs of his eyes, ears, feet and teeth had been covered by the input of regular appointments with the providers of these services. A comments card received from the health care professional stated that: This is a home where the staff have unusually high levels of skill. I have nothing but praise for them. The home uses the NOMAD (number of medications administered daily) system of medication storage and recording, and has a training video explaining the uses of this system to the staff. The care manager stated that this is used in conjunction with the internal training of the organisation, and that she and her deputy were first line registered nurses. She showed where in the care plans they kept an information sheet to be used should anybody be hospitalised, giving the staff there the most recent information about the medication being taken by that resident. On each page of the medication Administration record (MAR sheets) there was a picture of the residents to whom this information referred, which was thought to be helpful to staff of the home, all of whom had attended two full days of training on the administration of medicines. One resident self medicates, and signs his mousy whenever he has administered a dose. Risk assessments and protocols were seen, including protocol for as required (PRN) medications and when the MAR sheets were examined, no discrepancies or omissions were observed. 23 Mount Pleasant, DS0000004983.V317031.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality for this group of residents in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents were being protected by staff who were aware of all the issues surrounding abuse, and of their needs to assist these residents to make any concerns they had, known. EVIDENCE: In a formal interview with a member of staff the subjects of abuse and assisting residents to voice concerns was explored in depth. She said that they had formal training from the providers which was updated every three years, and that the Care Manager of this home was the facilitator who delivered this training. It was confirmed that this was consistent with the Learning Disability Award Framework and with the best practices of the British Institute for Learning Disability. She was aware of the extent to which the residents of this home were at risk of abuse, and was able to enumerate many things, both those being done to a resident, and those not done to a resident, and that would be abusive. She quoted the investigation into N. H. S. learning disability services in Cornwall, and spoke of further training updates that had been given to all staff in a workshop as a result of these findings. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 16 Since the last inspection no complaints had been received about the home, and no issues were raised in the comments cards sent to the commission prior to this inspection. One resident had been hospitalised after an incidence of selfabuse, and protocols were seen in his care plan setting out steps to be taken to try and prevent a reoccurrence of this. The complaints procedure has been included in the service users guide with appropriate pictures to make are doing more accessible to those residents who have challenged verbal and visual communication. 23 Mount Pleasant, DS0000004983.V317031.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, and 30. The outcome for this group of residents was good. This judgment was reached using all the evidence available including a visit to the service and was made as the residents were seen to be living in a homely, comfortable, and safe environment, with personal and communal space that met their needs and lifestyle, and helped to promote their independence, in an environment that was well maintained, clean, and hygienic. EVIDENCE: During a tour of the environment is the only area where any concerns was experienced, was the laundry. Reference had been made to this in the previous report of the 10 November 2005 when a recommendation was made that the missing tiles should be replaced to improve the appearance of the area. This inspector felt it was also necessary to improve the infection control standard of the area. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 18 The other thing mentioned in the recommendation had been addressed, and the storage facilities had been reorganised and improved. The bedrooms of the residents were of an adequate size and were all for single occupation, and were supplied with washbasins, but no ensuite toilet facilities. The different rooms reflected the different histories and interests of their occupant, with privacy locks on doors, and specialist equipment being provided in line with the assessed need of the resident. In one room there was much sensory equipment to help relax that particular person, and in another talking books were observed to add to the enjoyment of a resident of the visual impairment. In the third room there were special equipment to support a resident whilst lying on her side, and another person had proudly displayed various certificates reflecting achievements in her life. New equipment have been provided in the ground floor bathroom, with a hydraulic bath that provided spa and hair washing facilities and as well as being designed to protect the back of the member of staff using it by being capable of being raised to a comfortable working height after the resident had been made safe in it. The care manager stated that similar improvements had been agreed to the bathroom on the first floor in the current years financial budget. New furniture had been provided for the lounges since the last inspection, and this was of good quality and enhanced the communal provision of the home. The facility had been purpose-built, and included mobility aids in the form of handrails in the corridors, bathrooms, and toilet areas. The home appeared clean, tidy, and well maintained, and no malodours were encountered at any time during this inspection. The kitchens were in process of being decorated, with plans for further upgrade. The one area where some concern was felt, as stated above, was the laundry. Work done some time previously had left breaks in the tiles, and this had been commented on in the previous report of the 10th of November 2005. At that time a good practice recommendation had been made that these tiles should be replaced to improve the appearance of the area, and this is repeated with the addendum that it is also necessary to ensure good infection control measures. 23 Mount Pleasant, DS0000004983.V317031.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,and 35. Quality for this group of residents in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents were being supported by a sufficient staff group with a high level of NVQ training to level 2 and above, and were benefiting from recruitment policies and procedures aimed their protection, and a robust staff-training programme covering all mandatory subjects, and the particular needs of people with a learning disability. EVIDENCE: Employment rotas were provided for four separate weeks prior to the inspection, and these confirmed that there were three people on duty between 7:30 a.m. and 3 p.m. three people on duty between 2:30 p.m. and 10 p.m., and one member of staff awake and watchful, in between 10 p.m. and 7:30 a.m. the following morning. Observation made during the visits to the home showed that there was sufficient staff on duty to enable residents who lacked the capacity to access the community without support, to be able to go out and visit the shops or other facilities as they wished 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 20 An extremely detailed matrix of training planned and completed for 2006/07 was provided prior to the inspection, and discussions with staff on duty and reference to individual staff records confirmed the validity of this program. Records show that all staff had current accreditation in food and hygiene, First Aid, and moving and handling, and that 10 were qualified to NVQ level 2 or above, with two further people currently undertaking level two with completion dates in 2007. Over 80 of staff had received training in the management of actual and potential aggression, sexuality, medication administration, and bereavement and loss. Everybody had received training about abuse, and the protection of vulnerable adults. In a formal interview a member of staff confirmed this level of training activity, and that she had benefited from an extremely thorough induction process with the first week being taken up by academic input at the providers headquarters in Newcastle, before starting at the home where she had been put to work in tandem with a mentor, before undertaking any loan working. She also confirmed that the recruitment procedure had conformed with equal opportunities and employment legislation, and that the people she had named as how referees had been approached for written comment on her suitability, and that she had been required to demonstrate that she had a clean police record, before being able to start working with the vulnerable individuals who live at the home. These statements were further verified by examination of her staff record. 23 Mount Pleasant, DS0000004983.V317031.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. The outcome from this group of residents was good. The manager appeared competent in all she did, and to be running the home following the best principles of current thinking in good practice for people with learning disability. Further the records showed that the maintenance of the home had been appropriately undertaken, and that measures aimed at maximising the health and safety of all those in the home had been completed both spontaneously, and in line with the minimum intervals recommended. EVIDENCE: Both the Registered Care Manager and the deputy manager of this home are qualified nurses who have completed the Registered Managers Award. In discussion the care manager showed herself to be forward thinking and proactive in her approach to providing an holistic service to her residents. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 22 She had taken it upon herself to contact the local fire officer for an assessment of the safety of the home and its procedures in relation to dealing with any possible fire, and was actively implementing his recommendations. Certificates of registration and of insurance were up-to-date and were on display near the main entrance to the home, and such other records of compliance with legislation, as regular servicing of lifting equipment, gas heating systems, water temperature monitoring (including Legionella testing), and portable electrical appliances were either seen during the visit to the home, or confirmed in writing in the provided data sets that had been previously received. Records further showed that the fire alarm equipment was tested every week, with a rotating program to ensure that each position was included in the process, and regular testing of the emergency lighting took place at the recommended intervals, as did testing, servicing, and recertificating of fire fighting equipment and appliances. The action had been taken to address the crumbling tarmac in the car park, which had been commented on at the two previous inspections, and this no longer represented a possible trip hazard. Regular reports have been received following the monthly visits of a Principal Officer of the providers to home, to assess the quality of the service being provided to its residents. Additionally, the commission have been furnished with a five-point mission vision for improving the current level of service being provided, and residents meetings have been held and relatives/supporters questionnaires sent out and analysed, to capture the opinions of those people most directly affected by the quality of the service being provided. Comments cards were returned by one professional, three relatives, and three residents, prior to the inspection, and these were all very positive about the service. 23 Mount Pleasant, DS0000004983.V317031.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 4 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 X 23 Mount Pleasant, DS0000004983.V317031.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA30 Good Practice Recommendations The missing tiles in the laundry should be replaced, to improve the appearance of this area, and to improve the ability to maintain infection control. 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 23 Mount Pleasant, DS0000004983.V317031.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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