Inspection on 24/04/07 for Mablethorpe Hall

This inspection was carried out on 24th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mablethorpe Hall 09/07/08

Mablethorpe Hall 26/09/06

Mablethorpe Hall 24/04/06

Mablethorpe Hall 25/01/06

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

CARE HOMES FOR OLDER PEOPLE Mablethorpe Hall Alford Road Mablethorpe Lincs LN12 1PX Lead Inspector Mr Doug Tunmore Key Announced Inspection 24th April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mablethorpe Hall Address Alford Road Mablethorpe Lincs LN12 1PX 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) 01507 472661 Hamilton Community Homes Limited ** Post Vacant *** Care Home 24 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number disorder, excluding learning disability or of places dementia (11), Mental Disorder, excluding learning disability or dementia - over 65 years of age (13) Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:Mental Disorder, excluding learning disability or dementia, under 65 years of age (11) MD. Mental Disorder, excluding learning disability or dementia, who are over 65 years (13) MD(E). Dementia over 65 years of age (13) DE(E). Maximum number of service users to be accommodated is 24. 2. 3. 4. Date of last inspection 26th September 2006 Brief Description of the Service: Mablethorpe Hall is a care home providing personal care and accommodation for 24 younger adults and older people with mental health problems. The care home is owned and operated by a company, Hamilton Community Homes Limited, whose headquarters are in Leicester. The home is located on the outskirts of the coastal town of Mablethorpe. Transport such as, taxis are required to access shops, hairdressers, pubs and the other amenities, which are in the town, over a mile away from the home. The home is set in its own grounds and is accessed over an un-adopted road, which also services other properties. Mablethorpe Hall has been adapted and extended to provide accommodation for service users on two floors. The home is staffed as one unit, but comprises of two separate areas, being the main house and an annex. The current scale of charges at this home is from £348.00 to £428.00. Additional costs are made for hairdressing, chiropody and newspapers and taking taxis to town. These are all private arrangements and the individual service users meet these costs. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this announced key visit to the home. This visit took into account any previous information held by The Commission for Social Care Inspection (commission) including the homes previous inspection reports and their service history. The site inspection consisted of talking to two residents and tracking three residents care, which included looking at their records and assessing their care. The inspector joined residents for lunch and observed the care they received throughout this visit. The inspector spent time with the responsible individual for the home, the provider, one carer, and two visitors. The home does not have a registered manager and the responsible individual is overseeing the running of the home at the time of this visit. A partial tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? The home has taken action to address those requirements made in the last inspection of this home. Nationally recognised vocational training in care has now been made available for all staff to ensure that adequate numbers of trained care workers are available in the home. The home carries out risk assessments on those residents who are at risk of falls and use walking aids. Since the last inspection a new stainless steel kitchen has been fitted and carpeting and decoration of hallways has taken place. The extensive garden areas to the front and rear of the home have been improved. Residents commented that staff are very kind and helpful towards them and the meals are nice, ‘we have had some delicious puddings’. Observations made on the day of the visit were that residents are supported in meeting their aspirations with two residents taken to the housing department in order to apply for their own accommodation. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 6 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. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People coming into the home receive an assessment and know their needs can be met. Prospective residents have information to help them make a choice of where to live. Residents have the providers terms and conditions, which informs them of the cost of their care. EVIDENCE: A review of all information available prior to this inspection, including a previous inspection report dated 26/09/06 and evidence seen at this inspection in residents files and care plans, showed that the provider does not admit residents without a care needs assessment being undertaken. Prospective residents are also written to by the home confirming whether they can meet the residents care needs or not. A resident who was recently admitted did not have a care needs assessment completed by the provider. The resident Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 9 stated that he had lived in another home belonging to this company for some nineteen years and he stated that ‘they know all about me’. He also confirmed that he stayed in this home for a week before Christmas to see if he liked it and he stated that he does. He also commented that his community psychiatric nurse brought him to the home for his visit. Intermediate care is not provided in this home. Residents completed eleven questionnaires and ten stated that they did receive a contract on admission and seven confirmed they have information about this home prior to admission. Written comments made in questionnaires were, ‘social services moved me here from hospital and I am very happy with the home all round’. Three residents files were seen with all three having a written contract from the current provider, giving the terms of conditions of occupancy. Two care needs admission assessments were also available, which documented individual care needs. Letters were also seen on files confirming that the provider can meet prospective residents needs. The providers action plan was received on the 27/03/07 from the previous visit to this home by the commission on the 26/09/06. The action plan confirmed that all residents have terms and condition of their placement. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. Accurate records of the administration of medication are not kept, which would ensure that residents receive their medication when prescribed. EVIDENCE: A previous visit to this home evidenced that; daily entries had been made in care plans by care staff, which identified the care given. The homes accident book had been seen and it was found that accidents occurring to residents have been recorded appropriately in the residents file and body map. The homes service history held by the commission evidenced that the provider has informed the commission about those accidents or other incidents that has occurred to residents. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 11 Those residents who are able, are encouraged to sign their care plans and take a more active role in their care. This visit found that the files of residents who were being case tracked had care plans which had been reviewed. The responsible individual confirmed that residents under sixty-five were reviewed six monthly and those over sixty-five had their care reviewed monthly. The providers action plan further evidenced that all care plans are now reviewed. The provider has posted on the notice board the name and address of an advocacy service for those residents who are unable to take part in their care planning and do not have relatives to support them. The Social Services Department carried out some eleven care reviews of residents at this home in 2006. The Commission was informed by the reviewing social worker that all but one residents care needs were being met. A carer demonstrated that she had knowledge of the personal care needs of residents and that she treated them with respect and was mindful of their dignity. Residents files outline how staff were to address the issue of maintaining residents dignity and privacy when undertaking intimate care needs. Two visitors seen on the day of the inspection stated that residents privacy is maintained and that staff are very good. A resident stated that ‘staff speak to me all right, they are very friendly’. A written comment made by a resident was ‘ I have an emergency buzzer in my room which I can ring for staff if I get anxious’. Files seen in previous inspections confirmed that health care professionals visit the home when required by the residents. Residents confirmed at that visit that they see the chiropodist, dentist and visit the diabetic clinic. Residents files showed that they have access to the GP and district nurse. The questionnaires returned by residents showed that eight felt that they always receive the medical support that they need and two felt that they usually received the medical support that they need, one felt that he sometimes received the support he needs. The responsible individual was informed of the outcome of the questionnaires throughout the inspection. Five residents commented that they felt that staff are always available when they need them and five felt that staff are sometimes available when they need them. One felt that staff are sometimes available when he needs them. The pharmacist visited the home on the 28/03/06 and recorded that storage and administration records of medication is carried out appropriately. Medication sheets seen by the inspector had not been correctly completed in two instances by the senior carer on duty. One medication sheet had not been signed for medication given and another had been signed for medication, Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 12 which had not been given to a resident. It was noted in this visit and a previous visit to the home that not all medication sheets had photographs of residents to help carers to identify the right medication for the right resident. The responsible individual stated that this would be addressed as soon as possible. The responsible individual organised medication training for all carers during this visit for the 10/05/07. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a set menu, which has a range of choices for residents and accommodates individual dietary needs. Residents do not access community services or day care provision, which would meet their social needs. The range of activities provided by the home has improved since the last inspection. EVIDENCE: Two visitors were seen and they stated that they are regular visitors and are always made welcome by the carers at this home. They commented that both the staff and the atmosphere at the home is very good, its like home from home. Resident commented that they don’t get many visitors. Resident’s files seen did not evidence that they have access to community facilities or special day care provision for those residents who require this type of support. One resident said that he moved here recently and is waiting to get Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 14 a social worker and then ‘I’ll attend a day centre in Mablethorpe’. Residents care plans seen recorded residents likes and dislikes in relation to their daily living. The home has a policy relating to maintaining residents independence. Daily records seen evidenced that residents go to the local town as they wish to shop. Residents stated that they can go out when they so choose, to go shopping at least once or twice a week. Residents questionnaires showed that four felt that activities are always available, six felt that they were usually available, one felt that they were sometimes available. A number of written comments were on the lines of ‘I don’t like activities and I choose not to join in activities’. A have your say about… questionnaire has been received from a training assessor working for a nationally recognised training initiative (National Vocational Qualification) and who visits the home regularly. She stated that, ‘the home puts the residents first, the outings and activities are good’. The homes activities book was seen and evidenced that efforts are being made to introduce activities into the home. A carer stated that they all undertake activities with residents which includes; card making, Easter basket making, darts, painting and we celebrate birthday parties. On the day of the visit, the provider took two residents to the housing department so as to support them in an application for their own accommodation. The residents appeared very excited by the prospect of living independently and having their own house/flat. A previous inspection undertaken in April 06 found that there was a choice of meals on offer and the food prepared was hot and very tasty. The inspector received positive comments during this inspection from people who commented that ‘the meals are quite nice and I like cheesecake for pudding’. Another resident commented ‘I cook some of my own meals outdoors when its good weather. He also confirmed that there are activities and entertainment, like pantomime, visits to the garden centre and that he walks into town when the weather is good. The providers action plan confirms that they consult residents about their likes and dislikes. Residents questionnaires showed that six always liked the meals and three usually liked the meals and two residents sometimes liked the meals. On the day of the visit the cook was on sick leave and would be away for some time. The responsible individual stated that she is trying to get another cook as the staff are currently helping out in the kitchen. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People know how to make a complaint and feel that staff will listen to their views. Staff are aware of how to respond to a complaint or an adult protection allegation. EVIDENCE: This inspection found that the homes complaints process has a place for a complainant to sign to signify whether they agreed with the outcome of their complaint or not. A tour of the premises found that the homes complaints procedure was placed in resident’s bedrooms for their information. The home has also introduced a complaints box, which residents can ‘post’ their complaints if they so wish. The provider informs the commission in writing of any incident within the home which results in an injury to a resident. The providers action plan states that if any issue arose the provider would notify the appropriate authorities. One carer confirmed that she has undertaken in house safeguarding vulnerable adults training and that she would report any concerns to the provider. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 16 One resident commented that he feels safe with care staff and that they have given him a key to his own room. Resident’s questionnaires showed that ten knew how to make a complaint and seven knew who to speak to if they were unhappy. None of residents, staff or visitors had any concerns about the home. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have taken place since the last inspection to the environment especially to the kitchen. The provider does not keep all residents rooms clean and comfortable for them to live in. EVIDENCE: A tour of the premises was undertaken. The home was clean and tidy in all communal areas, but in one residents room support is needed to maintain a better level of cleanliness. The lounge and dining room has new carpets, a new kitchen has been fitted and corridors and stairs have been repainted. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 18 Visitors stated that there have noticed new carpets fitted and everything is clean and tidy. The training assessors questionnaire noted that cleanliness has improved over the last six months and since July 06 the homes décor has improved, as have the gardens. Residents files evidenced that risk assessments are available relating to environmental hazards. The providers action plan stated that risk assessments are carried regarding hazards to resident’s safety. The handyman was seen fitting a new carpet in the office on the day of the visit. It was brought to the attention of the responsible individual that one residents room did not have adequate bedding, which was unsuitable for his needs, being stained and dirty and with no sheets, duvet or pillow covers. She explained that she would give the resident funds to buy his own bedding as he was very independent and would respond to this approach. A resident stated that he is satisfied with his room and the home generally, but ‘I have asked for my room to be cleaned and this has not happened yet’. The providers monthly visit report dated 14/03/07 showed that ‘due to the lack of a domestic worker staff are having to clean’. The responsible individual commented that the home is without a cleaner at present and she is trying to employ one as soon as possible. There was no noticeable odour during the visit. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust recruitment practices. Improvements have been made to the training of staff to meet the needs of the people living in the home. However, staff shortages reflect on the care and support for residents, which needs to be increased. EVIDENCE: In 2006 the Local Authority contracting monitoring visit found that ‘ it was evident that a POVA/CRB checks (Current Criminal Record Bureau & Protection Of Vulnerable Adults checks) had been carried out in respect of the most recent person employed’. This inspection found that the provider had undertaken appropriate checks on new carers as required by law. The home has obtained The General Social Care Council Codes of Practice, which sets out responsibilities as care workers looking after vulnerable adults. The responsible individual stated that all carers have been given a copy of this document. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 20 Personnel files and training profiles evidenced that; all carers undertake the inhouse induction training. However, the homes ‘Skills For Care’ training pack for new carers has not been used. The responsible individual commented that this would be introduced within the next month. She also stated that six carers have started a nationally recognised training scheme, which would equip them to carryout their jobs as carers. The training assessor confirmed in her questionnaire that carers are undertaking training and that ‘she has seen good practice and that ‘staff from day one have been approachable and friendly and willing to learn’. The homes rota was seen and it was found that the home is currently without a cook and a cleaner. One carer stated that ‘staffing levels are normally good with three on in the morning and three in the afternoon, but we are very stretched at the moment and we tidy as we go along’. The responsible individual who works thirty hours a week at this home has not recorded the hours she works at the home the staffing rota. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The present management structure is inadequate therefore people’s needs are at risk. Service users are potentially at risk as there are no staff with the skills to manage the home if the providers were to become absent. Records show that residents’ health and general welfare and safety are promoted. The provider does not ensure that that the residents have the opportunity to voice their views and opinions. EVIDENCE: Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 22 This home is currently without a registered manager and has been since November 05, with the responsible individual taking on this task. The provider evidenced at this visit that a possible candidate for the managers post may be appointed within the next month. The commission must be kept informed about the progress of the providers efforts in employing a manager. There was no evidence available to show that the home conducts an in-house quality check on the services received by residents and visitors or report. The responsible individual confirmed that this requirement had not been met and that within the next month a quality check would be undertaken relating to the care received by residents. The providers action planed stated that a quality check would be undertaken by April 2007. A previous inspection found that the provider deals with a number of residents personal allowances, with seven residents managing their own monies. Some residents are subject to power of attorney, guardianship orders with their finances managed by the social services department/the courts or their families. Receipts are kept of monies spent by residents. Three residents monies were checked against the record of monies held on their behalf and it was found that accurate record was kept. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was evidence in the homes preinspection questionnaire that that fire alarms, fire drills and emergency lighting had been tested. Care staff receive fire training as part of the homes initial training and as a regular training event. The providers action plan confirmed that all fire equipment had been tested. The providers pre-inspection questionnaire showed the shaft lift had been serviced on a six monthly basis as required. Risk assessments are available for windows on the first floor, which do not have window restrictors. The provider’s action plan confirmed that risk assessment have now been completed of all first floor windows. The provider visits the home on a monthly basis and carries out an inspection. This visit found that monthly reports are available from the provider and that issues are raised regarding the running of the home. Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 X X X X 2 x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 3 Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Requirement The medication record sheets must be kept as an accurate record so as to record when and to whom prescribed medication is given. All bedrooms must be kept clean and this should be monitored to ensure that people are living in pleasant surroundings. The state of bed linen (duvet covers, pillow covers and sheets) must be monitored and a programme of replacement identified for frayed/worn and dirty linen. This ensures that people living in the home have acceptable bed linen. Staffing levels must be maintained to ensure that residents are given the individual levels of support they require to ensure their health, social and general welfare is maintained. An effective quality monitoring system based on seeking the views of residents/relatives and visitors must be undertaken with the results of any surveys DS0000065213.V335242.R01.S.doc Timescale for action 25/05/07 2. OP19 23(2)(d) 25/06/07 3. OP24 16(2)(c) (e) 25/06/07 4. OP27 18(a) 25/06/07 5. OP33 24 (3) 25/05/07 Mablethorpe Hall Version 5.2 Page 25 published for their information. (Timescale of 25/11/06 has not been met) with a new timescale been set. 6. OP31 9 The provider must appoint a (2)(a)(b)(i suitably qualified and )(c) experienced manager to the home. The commission must be kept informed of progress relating to an appointment. (Timescale of 25/11/06 has not been met) with a new timescale been set. 25/06/07 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 OP9 Good Practice Recommendations Resident’s photographs should be included in the front of their medication sheets to ensure that the right medication is given to the right person. This recommendation has not been met. The provider should consult with residents, health care and social workers concerning community day care provision for residents. No action has been taken. 2. OP13 Mablethorpe Hall DS0000065213.V335242.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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