Inspection on 20/04/07 for Aden Mount

This inspection was carried out on 20th April 2007.

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

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

Other inspections for this house

Aden Mount 15/04/08

Aden Mount 15/11/05

Aden Mount 16/06/05

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Aden Mount Perseverance Street Primrose Hill Huddersfield West Yorkshire HD4 6AP Lead Inspector Jacinta Lockwood & Cathy Howarth Unannounced Inspection 20th April 2007 5:15pm X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aden Mount Address Perseverance Street Primrose Hill Huddersfield West Yorkshire HD4 6AP 01484 515019 01484 533985 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) Aden House Ltd Mrs Wendy Lawson Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (18) of places Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The OP category of registration includes both residential and nursing care, with a maximum of 10 beds being used for nursing care. 19th September 2006 Date of last inspection Brief Description of the Service: Aden Mount is a purpose-built spacious home situated in Primrose Hill, a residential area of Huddersfield. It is situated on the same site as its sister home, Aden View. It offers personal and nursing care and accommodation for up to 27 older people and care for up to 18 people aged between 18 and 65 years. with a physical disability. . All bedrooms, which are over three floors, are single en-suite. All floors are accessed via a passenger lift or stairs. There is access to the home via a ramp for people in wheel chairs and there is a car park to the front of the home. There is a small garden area to the side of the home were service users can sit out, weather permitting. The Commission was informed that as at 17/04/07 fees ranged from £358 to £1,200 per week. There are additional charges for hairdressing, chiropody and aromatherapy. Information about the home in the form of a Statement of Purpose and Service User’s Guide and the latest inspection report can be obtained from the home. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors visiting the home unannounced. The manager provided information about the service before the inspection visit and surveys were sent to a selection of people who live at Aden Mount and their relatives and health and social care professionals involved with people living there. Reponses to these surveys have informed the judgements made within this report along with conversations with people living and working there on the day, and two relatives who were visiting. Inspectors would like to express their appreciation for the welcome they received from people living and working at the home at the time of this visit. What the service does well: What has improved since the last inspection? Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 6 Care planning to meet people’s physical needs has improved, with the introduction of a new system with good regular monitoring of the plans. This makes sure that the information is always up to date and that people are getting the support they need. Safe storage arrangements for oxygen used in the home have been put in place. Bars of soap are no longer provided in communal bathrooms, minimising the risk of cross infection. Fire risk assessment has been updated. Accidents and incidents have been reported as required to allow these to be monitored by the inspector responsible for the home. 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 Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 2, 3 and 6 YA 2 and 5 People using the service experience good quality outcomes in this area. People choosing this service are properly assessed and generally admitted in a way that gives them time and space to make their decisions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Aden Mount does not provide intermediate care. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 10 There are good assessment and admission processes in place at the home. People are assessed to ensure that the home can meet their needs and people said they felt were given good information about the home and what is available before moving in. The home provides some short stays and this can sometimes help people to gain an understanding of what it is like to live there before committing to live there on a permanent basis. Otherwise people may be invited for tea visits to see if they like it. The manager carries out her own assessment before admitting someone to the home. Contracts for people living there were looked at and did generally contain reasonable conditions for people. However one clause stating that the company does not accept responsibility for lost or damaged laundry might be seen to be unfair. This should be reviewed with reference to the Office for Fair Trading’s leaflet “Fair Terms for Care”. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7, 8, 9 and 10 YA 6, 9, 16, 18, 19 and 20 People using the service experience good quality outcomes in this area. Individuals’ health and personal care needs are generally well met but some improvements could be made in respect of addressing social, emotional and cultural needs. This judgement has been made using available evidence including a visit to this service. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 12 EVIDENCE: Inspectors looked at the files for four people in details and spoke to people about their care. The plans showed a good level of detail especially in relation to the physical needs which people may have had. The new format seen at the last inspection has been extended throughout the service and this has improved the quality of the information provided to staff about people’s needs. In some cases there could have been more detail, for example instead of saying ‘nurse on appropriate mattress’ it would be more helpful to identify the specific type required so that this is clear to all staff what is required. There is a good system for monitoring the plans, which are reviewed monthly and were found to be up to date. One area for development in care planning is in addressing the social and emotional needs of people more clearly. The plans are very much based around the physical needs that people have, but for some people the emotional and social aspects of living may be equally important. In one plan for a Muslim person, the details around death and dying were not completed. Also the person indicated to the inspector that they would like to visit the mosque but did so rarely. This may reflect a lack of awareness in the staff team about this issue and particularly in understanding the cultural norms relating to death in this culture. However, it is important that this is addressed with the person and their family should that event occur so that staff know what is required. Staff training in understanding norms in the Muslim culture is recommended to ensure that these needs can be properly met. Risk assessments were seen as part of these plans for people and were generally good reflecting the lifestyles of individuals and were generally up to date. There is a clear policy for the safe handling of medicines within the home. One person is responsible for medication and has access to the keys. There is storage for controlled drugs and these are properly accounted for in a separate book and double signed. Other medicines are contained in drugs trolleys. A sample of medicines was spot checked as part of this inspection and were found to be correctly managed and stocks balanced. Where appropriate, people are supported to manage their own medication. This was found to be properly risk assessed and safe storage is provided to the person in their bedroom for the drugs. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13, 14 15 YA 7, 11, 12, 13, 14, 15 and 17 People using the service experience good quality outcomes in this area. People have a good range of choice for their daily activities but may need more support to follow their interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 14 The area of daily life and lifestyle choices is one where the home could perhaps make some improvements. People responding to surveys indicated that more activities and stimulation could be provided at the home. People who spoke with inspectors also reflected this view and it had been raised in a quality assurance survey in October 2006. On the day of inspection there were few activities apparent, although some people are able to go out and participate in community activities such as college courses. Within the building this needs to be developed further. The home does have an activities organiser but inevitably in such a large building they cannot provide the stimulation required for everyone. Some people indicated that they felt that the lack of staff on occasions means that they do not have time to spend with people to make sure they get stimulation. One aspect that was positive during this visit was that inspectors observed family and friends being made welcome in the home, spending time with and being able to enjoy meals with their relatives. Relatives have generally reported being made welcome by staff. One person indicated to an inspector that they would like to attend religious services but this does not happen at present. Again this was an issue that emerged from the home’s own survey in 2006. The lunch was served in a relaxed manner with plenty of staff to help support people. Choices were offered and meals were served at a later time for one or two people who did not want to eat at that time. One relative responding to the survey did indicate that they had experienced some difficulty with their relative not receiving food all day because of attending a hospital appointment. It is important that these issues are monitored and meals provided for people who may be absent at mealtimes for whatever reason. Alternatives were offered for people on special diets including diabetic diets. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16 and 18 YA 22 and 23 People using the service experience good quality outcomes in this area. People are well protected within the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at Aden Mount are given clear information about how to complain and this system is used effectively. Complaints are responded to in writing and within the given timescale of 28 days. The service takes the protection of its users seriously. Incidents where staff have alleged to have been involved in mistreatment of people have been dealt with appropriately and following the local procedure. One cause for concern was that the internal procedure indicates that staff should interview witnesses and take statements. This is not in line with procedure and should be changed to avoid a situation where evidence for the police may be contaminated by Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 16 prior actions. As this policy is current across all Aden services this needs to be addressed centrally by the responsible individual. Staff receive training in the protection of vulnerable adults as part of their basic training in the service. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19, 22 and 26 and YA 24, 29 and 30 People using the service experience good quality outcomes in this area. The home is well maintained, clean and tidy and suitable to meet the needs of people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 18 A tour of Aden Mount was conducted which included a selection of residents’ bedrooms. The home is purpose built and has wheelchair access including a ramp to the front entrance. There is also a passenger lift between floors. The interior, which is well maintained, provides a homely and comfortable environment for residents living there. There is a small well-maintained garden to the side of the home. In addition to the main communal areas, the Thompson Unit has a life skills kitchen, where people can make their own snacks and a laundry where they can wash and dry their own clothes if they wish. People who spoke with inspectors expressed satisfaction with their rooms saying they like the space and the fact they have their own bathrooms. One relative who returned a survey said there was: “an excellent standard of accommodation.” One inspector visited the room of one person who was having an environmental control system fitted that day. Although the person was a wheelchair user unable to use his hands, all the electrical systems in the room, including the nurse call system could be operated by his head using a switch on the wheelchair. This increased his independence within his own space considerably and he was very pleased with the system. The main laundry is large and well equipped. Some people in their responses to surveys indicated that loss of laundry was a problem in the home and also a complaint made last year indicated that this was a problem. Efforts should be made to implement a system to minimise loss and damage to laundry. As part of this inspection, maintenance records for the building and equipment was inspected and found to be up to date. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27, 28, 29 and 30 YA 32, 34 and 35 People using the service experience adequate quality outcomes in this area. There are not always sufficient staff with the right skills, and familiarity with people living at Aden Mount on duty. Some improvements should be made in tightening up recruitment checks for the safety of people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this visit the home was experiencing some difficulties with staffing as there were a number of vacancies to cover and one person had been suspended. Agency cover was being provided but this is less than Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 20 satisfactory in terms of continuity of care for people with complex needs in some cases. Inevitably the quality of what can be delivered to people is affected if staff do not have the familiarity with care plans and the personalities of service users, especially where they have significant barriers to communication. The manager has started a process of recruiting casual bank staff so that the people living there will know people working at the home. Two people who responded to surveys and people who spoke with inspectors indicated that there are times when there are not enough staff around. On the day of this visit, however, there were plenty of staff on duty, especially at mealtimes when there were staff in sufficient numbers to ensure that each person had individual attention as needed to enjoy their meal. Inspectors also observed staff responding promptly to call bells. Training at the home has improved since the last inspection. The manager has completed a skills audit and identified where there are gaps to be filled in staff skills and knowledge. A programme has begun to ensure that staff gain training in first Aid and infection control. Staff are given the opportunity to gain NVQ2 qualifications. At the time of this inspection only nine out of thirty-two care staff had this or equivalent. This is around 33 of staff, which is lower than recommended in the National Minimum Standards. Training is an area that needs some sustained attention to ensure that the overall skills base within the home is at a good level to ensure people are safe and well looked after. Recruitment systems are generally good within the home. New staff are checked through references and have enhanced CRB disclosures. In circumstances where staffing is urgent staff may start work with only a POVA First check. These staff work supervised. Whilst most of the system works well it would be helpful to make some improvements for the welfare of people living at Aden Mount. For example one file showed that a full employment history had not been obtained for one person and on another a more suitable reference than a family friend could have been contacted but was not. These are important steps that can be taken to ensure that every avenue has been taken to protect people from unsuitable workers. New staff are given a detailed induction and have a workbook that they go through with their supervisor to ensure they have covered everything the need to know in the first six weeks of their employment at the home. One new worker who spoke with an inspector said they had had a good induction and having two weeks as a supernumerary worker enabled them to get to know the routine before being expected to work as a full team member. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 22 OP 31, 33, 35 and 38 YA 23, 37, 39 and 42 People using the service experience good quality outcomes in this area. The management of the service is good and health and safety of people living and working there is protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of Aden Mount is well qualified and experienced in this area of work. Unfortunately she informed inspectors that she would be leaving within weeks of this visit. The company will therefore need to find another manager to carry on the improvements made so far. Inspectors found that the overall management of the home was good. There are systems in place to ensure that checks are carried out and that the home runs smoothly for the most part for the benefit of people living there. There are regular meetings held for people living at Aden Mount to express any concerns or make suggestions for improving the home. In addition a survey was conducted in October to elicit people’s views of the home and how to improve it. This resulted in significant changes to the menu choices to better reflect the preferences of the younger age group. People living there said they appreciated this and found the meals much improved. Another survey was apparently conducted for relatives’ views around the same time. Unfortunately the outcome of this survey was not available. The organisation arranges for monthly visits to be carried out to ensure that the service is operating effectively and meeting standards. Reports from these visits are made and the manager responds with actions and timescales. This system seems to be working effectively. Some people living at the home have their money kept for them by the home. These were checked during this inspection visit and were found to be satisfactorily safeguarded by the system in place. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 23 Records required to be kept were found to be up to date. Health and Safety systems were working effectively in terms of reporting accidents and getting repairs done in a timely way. The home’s fire risk assessment has been updated as required to meet the requirements of the Fire Regulatory Reform Order. Fire safety systems were effective. Tests and drills were up to date and training for staff has been given along with drills. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 3 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP27 YA33 Regulation 18a Requirement There must be sufficient suitably experienced and qualified staff on duty to meet the needs of individuals living at the home at all times. Timescale for action 30/06/07 Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP2 YA5 OP7 YA6 OP7 OP11 YA11 OP12 OP18 YA23 OP28 YA32 OP29 Good Practice Recommendations The contract should be reviewed to ensure it is fair to people living at the home. The plan for each service user should reflect the wide range of their needs including social and emotional as well as physical support they may need. Staff should be trained in understanding other cultures so that people may be treated in a way that they are used to according to their norms. People should be supported to attend religious services if they wish and this should be recorded on their care plan and monitored. The procedure for responding to allegations of abuse should be amended so that staff do not act in a way that conflicts with the local policy and procedure. 50 of staff should have a minimum of NVQ2 qualification or equivalent. When recruiting staff full employment history should be obtained with a written explanation of any gaps. References should be sought from appropriate sources e.g. employers in preference to family friends wherever possible. 7 Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. Aden Mount DS0000061700.V336883.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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