Inspection on 16/08/06 for Mansion House

This inspection was carried out on 16th August 2006.

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

The inspector 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

Mansion House 30/07/07

Mansion House 27/01/06

Mansion House 08/09/05

Mansion House 24/03/05

Mansion House 06/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mansion House Burnham Road Althorne Maldon Essex CM3 6DR Lead Inspector A Thompson Key Unannounced Inspection 16th August 2006 09:30 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 Mansion House DS0000017878.V308932.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. Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mansion House Address Burnham Road Althorne Maldon Essex CM3 6DR 01621 742269 01621 742269 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) Mr Francis George Kirk Ms Simone Walmsley Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 36 persons) 27th January 2006 Date of last inspection Brief Description of the Service: Mansion House is a fully detached period property with the original building approximately 600 years old. Its location is on the eastern edge of the village of Althorne which is approximately two miles from the nearest town of Burnham on Crouch. The original building has been considerably extended and is registered to provide accommodation for thirty six elderly people (over the age of 65) in twenty eight single and four shared rooms. Accommodation is provided on two floors. There are four communal lounges and two communal dining rooms on the ground floor. Access between floors is provided by a passenger shaft lift. Mansion House is set in spacious enclosed grounds, which are accessible to residents. Ample visitor car parking is available to the front of the property. Public transport links include a bus service along the main road directly in front of the home and rail services approximately one mile away in Althorne Village. A local shop is also located in the village. Information was not collected regarding the fees charged. Past inspection reports are available from the home, and from the CSCI internet website. Mansion House DS0000017878.V308932.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 took place on Wednesday 16th August 2006. The content of this report reflects the inspector’s findings on the day of the inspection along with information provided by the service and feedback by service users, relatives, staff and other parties. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Discussions took place with nine service users, the registered provider, deputy manager, six members of staff and two visitors. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All residents spoken to expressed full satisfaction with the care they received and with the quality of the food and accommodation offered. Visitors spoken with were complimentary of the care and support provided to residents by the staff and management team. Questionnaires were left at the home so that relatives not spoken with on the day had the opportunity to make their views on the service known to the Commission. Staff confirmed they received support from management. They also confirmed that they had been offered NVQ training. Twenty-nine standards were inspected with twenty-four met and five almost met. What the service does well: What has improved since the last inspection? Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 6 There are three new bedrooms, a new communal lounge and a new communal wc. Improvements have been made to the grounds allowing better access for residents. What they could do better: All care plans must be fully completed and the electrical installation supply required retesting. Daily records should be available of activities offered to residents. Staff trained to NVQ 2 level should make up at least 50 of the care staff team. Medication training to staff should include written evidence that a competency assessment in administering medication is carried out on staff before they undertake this responsibility. -------------------------- 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. Mansion House DS0000017878.V308932.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 Mansion House DS0000017878.V308932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home’s assessment format and process ensured that initial perceived needs were identified upon admission. Anyone considering moving into the home may visit to meet residents, staff and facilities, to enable them to assess the suitability of the service Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 9 EVIDENCE: The manager of the home or the deputy manager visit prospective residents to carry out a written assessment. The assessment format was seen and includes headings of: background information, next of kin details, medication, manual handling needs, social interests and need, general health needs, mobility, vision, hearing, diet, sexual needs, continence, and includes full manual handling assessment. A separate social history record is also completed and was also seen. There was also a separate written assessment of potential pressure area risk. Prospective new residents are invited to visit Mansion House prior to deciding on a placement, to try to ensure full awareness of facilities available and providing the opportunity to meet with existing residents and staff. Lunch would be offered during these visits. Residents and visitors spoken with confirmed they were invited to visit. The homes assessment format is completed in addition to any local authority placement assessment. Mansion House DS0000017878.V308932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health, personal and social care needs of residents were adequately detailed in individual plans of care, however not all were fully completed. Health care needs of residents were met and residents felt they were treated with respect. EVIDENCE: Three care plan files were inspected. These contained admission information, such as next of kin, with a social history and health history, however one had not been fully completed and this shortfall required addressing. Care plans are compiled using the homes needs assessment format with daily plans of care and instructions to staff under main headings of mobility, continence, sexuality and sexual health, special needs, communication, personal care, mental health, pressure management, nutrition, dental, hearing, sight needs and social preferences. Individual needs are recorded with problem/need, instructions/goal and daily action required. Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 11 Care plans inspected had been regularly reviewed, although not monthly. Individual risk assessments covering identified hazard and risk rating with the perceived consequences and measures to control the risk had been completed. These were held separately from care plan files. Separate manual handling assessments had also completed. Residents personal and oral hygiene needs had been recorded in the homes assessment format and individual care plans. District nursing services provide tissue viability assessments and guidance/advice on continence issues. District nurses also visit the home to provide nursing services to residents, including those suffering from diabetes. The home has access to a continence nurse and an Occupational Therapist will visit to assess residents for any walking aid needs. Equipment for the promotion of tissue viability and prevention or treatment of pressure sores is also provided by district nursing services. Chiropody, optician tests and dental services are undertaken at the home by visiting practioners. Residents had been referred to St John’s Hospital in Chelmsford for some dental treatment, which could not be performed in the home. Hearing tests are available at a local hospital after referral by the GP. GP practices are provided in Burnham on Crouch and Southminster. The homes policy on the ordering, supply, administering, storage, security and disposal of medicines provided clear instructions and guidance to staff on the required procedures. The manager had provided in-house training to staff on the home’s procedures. One suggestion for improvement relating to medication training is for a practical, recorded, assessment of competency to be undertaken before staff undertake the role of administering medication. Dispensing/pharmacy services are provided by the local GP practices, Records confirmed that medication received into the home is always checked in and unused returns are recorded. Medications kept in the home were considered appropriately stored and there were no gaps in administration records inspected. Initial training is provided by senior staff, to staff who have been identified as possessing the competencies required to be considered for undertaking the role of administering medication in the home. It is understood that only senior carers and management undertake this role. External foundation training on medication issues has been provided to all staff administering or wishing to be considered to take on this responsibility. Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 12 Seventeen residents had private telephone lines installed in their rooms, for the remaining residents private telephone facilities are provided for by the availability of the office portable telephone. Discussions with individual residents indicated that they were treated with respect by staff, as did observation of staff going about their duties and interactions with residents. Staff on duty were seen to be courteous, caring and professional in their dealings with residents, and residents spoken with said staff were helpful and considerate. Visitors spoken with also confirmed that staff were caring and professional. Mansion House DS0000017878.V308932.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 at least once during a 12 month period. 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 lifestyle experienced within the home largely matched the expectations of residents. They were able to maintain contact with family, friends and participate in the local community. Residents were offered a varied, appealing balanced diet and were supported to exercise choice in their daily lives. EVIDENCE: Residents meetings continue to take place, records were available for inspection. Meetings occur approximately four times a year. Items discussed included menus, outings, activities and general day to day issues. These meetings are chaired by a resident, who then liaises with management on issues raised. Residents spoken with confirmed they were fully satisfied with the choices and options made available to them regarding daily routines and leisure interests on offer. They were also complimentary about the care support provided by the staff team. Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 14 Activities records are maintained but those seen had not been completed on a daily basis, nor did they include activities offered in the afternoons. In-house activities are decided on each day according to group choice, a member of staff is designated each day to lead activities. In summer there are outings, residents agree destinations. There is also a summer fete and regular coffee mornings and a weekly visit from an organist who plays in the rear lounge. Discussions with residents confirmed that some go out with staff to garden centres and the local pub. They also confirmed they were generally satisfied with the range of activities although some would like the opportunity of more offered in the afternoons. A hairdresser calls to the home once a week, the mobile library calls monthly, book clubs visit monthly and a clothes shop visits occasionally. Holy Communion services are available in the home on a monthly basis by a visiting local clergywoman. The home supports all residents regarding individual spiritual needs. A volunteer visitor also calls into the home. The main meal of the day is lunch (choice available) with usually a hot or cold choice at tea. Some residents also have a supper snack meal of sandwiches or cake before bedtime. The manager has advised that snacks are also available at night for residents who may be awake. Some residents choose to eat in their rooms the remaining eat in the home’s dining areas. All residents except one (by choice) have breakfast in their rooms. The chef confirmed that cooked breakfasts were available. A member of staff is always on duty in each dining area at mealtimes to offer assistance and support. Nutrition records and menus evidenced that a range of choices is available with appropriate nutritional content. Residents spoken with said the food was very good and that there was always a choice at lunch and tea. Discussion with staff and observation confirmed that food stocks were kept at a good level. Mansion House DS0000017878.V308932.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 inspected at least once during a 12 month period. 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. Residents knew how to complaint and the home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. The home’s adult protection policies, procedures and practices were aimed at ensuring residents welfare. EVIDENCE: There had been no recorded complaints since the last inspection. The complaints policy included information to the prospective complainant on whom to complaint too with response timescales. There were also contact details of the registration authority. A copy of the policy is included in the information provided to new residents. Residents spoken with said they knew who to speak to in the home if they any concerns, and that in the past management had responded positively to any queries/issues they had raised. The home had a staff training video package entitled ‘abuse in the care home’. This is shown to all new staff as part of the home’s induction procedures. Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 16 The home also had the latest Essex Social Services guidelines and procedures relating to adult protection and actions expected from staff under this subject. Included were recording and reporting templates and procedures along with definitions of the various recognised types of abuse. Also in place were the Department of Health’s POVA and the Essex Vulnerable Adults Committee (EVAPC) booklets on abuse. Records and discussion confirmed that staff had attended the EVAPC half day POVA training scheme on adult protection. The home’s ‘whistleblowing’ statement/policy was seen and provided appropriate guidance to staff. Mansion House DS0000017878.V308932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Furnishings in the home looked comfortable and areas of the premises seen were very well maintained. Private accommodation was comfortable and suited to needs and preferences. The premises appeared generally safe, were accessible, and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was clean and considered to be hygienic. Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 18 EVIDENCE: Mansion House is a large detached property set in well maintained private grounds. Following inspection of the premises the inspector considered that the home is accessible and well maintained. The needs of individual residents are provided for and accommodation was regarded to be comfortable and homely. Residents have access to the grounds. Several rooms also benefit from the use of small private, individual, walled and paved patio areas. General day to day maintenance is undertaken by the designated maintenance person. There were six communal rooms available for residents, combined space met the recommended standard. Lighting in communal rooms was domestic type and appeared sufficiently bright and positioned to facilitate reading and other activities. Furnishings in communal and private rooms were also considered to be domestic in character and of good quality. There were five bathrooms in Mansion House three of which offered assisted bathing facilities. All bathrooms had wc’s. There were five separate communal wc’s available in the home and twenty seven private bedrooms benefit from fitted ensuite toilets. Rooms inspected were personalised to individual tastes, naturally ventilated with windows and were centrally heated with radiators fitted with thermostatic control valves. During discussion with residents all said their rooms were comfortable and that they were able to bring in personal items when they moved to Mansion House. Lighting in private rooms was considered to be domestic in character and included table level lamp lighting according to individual needs/risk assessed. Emergency lighting is fitted throughout the home. The homes laundry room was fitted with two washing machines both equipped with sluice cycle programmes and washing programmes that met the standard. There were two tumble dryers. The laundry floor finishes were considered impermeable and readily cleanable. Policies and procedures were in place for the control of infection and include safe handling and disposal of clinical waste. Throughout the inspection the premises were considered very clean and free from any offensive odours. Mansion House DS0000017878.V308932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels appeared to meet the needs of residents. Staff were provided good training opportunities to equip them with the skills for their role, although some had been unwilling to participate in NVQ awards training. Staff recruitment procedures aimed at the protection of residents had been followed EVIDENCE: The homes staffing rota was inspected and evidence staffing levels are being provided at five carers on morning shifts with four carers on afternoon shifts with a fifth carer from 1700-2100 hours. Two waking carers work night shifts. The manager and assistant manager’s hours were supernumery. Staffing rotas also evidenced that separate and additional staff are employed for catering, domestic and maintenance duties. One member of staff has the NVQ 2 and two staff were undertaking the NVQ level 2 award with two on the NVQ level 3, although management advised that generally established staff were still not supporting/accepting the offer of NVQ training. Full funding support is available. This training is offered to new staff joining the home. Staff spoken with confirmed this. Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 20 The assistant manager had the NVQ level 3 and the manager had NVQ level 4. Staff recruitment procedures were inspected. Two written references, proof of ID, application forms and CRB checks were obtained on new staff. Also on files were training records and contracts of terms & conditions of employment. Staff spoken with confirmed that they had interviews and CRB checks. The home’s induction and foundation training process was unchanged. This was based on a workbook format consisting of four modules for induction. These included subjects of principles of care, records, fire & security, manual handling, health & safety, risk assessment, infection control, food hygiene, care of service users, practical care skills, care & use of equipment, needs of service users, activities, settings, specific disabilities. On completion there is a written test paper to complete and a certificate of completion to acceptable competencies is awarded. Discussions with staff and inspection of training records and certificates confirmed that they received induction training and that short course training was provided which included: first aid (senior staff are trained to the full ‘First Aid at Work’ level), diabetes, bowels & catheter care, bereavement & loss, COSHH, infection control, manual handling, fire safety, stroke awareness, induction & foundation, continence including fluid monitoring, continence promotion, funeral awareness, bladder & bowel care, POVA (vulnerable adults) & medication. The manager had undertaken a Dementia ‘train the trainer’ course, which qualifies her to train staff in-house. Mansion House DS0000017878.V308932.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run and managed efficiently and effectively. Procedures for gaining the views of residents, relatives and visiting professionals were in place. Records required by regulation were in place. Financial practices in the home appeared to have been competently managed. The health and safety of residents and staff was generally assured but testing of the electrical installation supply was overdue. EVIDENCE: The manager is qualified to NVQ level 4 in Health & Social Care and had completed the Registered Managers Award (certificates seen). Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 22 The home’s quality assurance system had last been fully implemented in 2005. Questionnaires had been provided to residents, relatives and other appropriate persons/agencies (ie district nurses). Sections include questions on staff attitudes, staff knowledge, managers knowledge, food, cleanliness, odour control, atmosphere, entertainment, outings, residents meetings, support provided for healthcare needs, admission process, medication, keyworker system, noise levels, privacy and any other comments. A Q.A. audit and action plan had been compiled from responses received. This consisted of written summaries of identified problem areas, actions taken by whom and the date. A discussion took place with the registered provider regarding monthly regulation 26 reports. These do not have to be sent to CSCI but copies do need to be available for inspection in the home. Some residents chose to entrust their personal allowance monies to the home for safe keeping. Records of balances held and of transactions undertaken were presented for inspection and were considered to be appropriately maintained. Remaining residents retained control of their own finances. Random samples of records required to be kept were inspected. These included care plans, assessments, fire procedures, fire drills, regulation 37 notices, accident records, staff rotas, complaints, cash held for safekeeping, staff recruitment, items brought into the home, visitors, photograph of service users & medication. Discussions with staff, management and inspection of records confirmed that training is provided to staff in moving and handling training, fire safety, food hygiene, first aid and basic training in infection control. The registered provider, deputy manager and some records seen confirmed that fixed and portable hoists, fire alarms, fire fighting equipment, staff call bells and shaft passenger lift had all been tested at appropriate intervals, however the last test of the electrical installation supply expired in December 2005. The registered provider undertook to address this shortfall without delay. The registered provider retains responsibility for ensuring that the home’s portable electrical appliances are tested annually. Mansion House DS0000017878.V308932.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 X X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 24 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 2 Standard OP7 OP38 Regulation 15 13,23 Requirement The registered manager must ensure that all care plans are fully completed. The registered provider must arrange for the retesting of the home’s electrical installation supply. Timescale for action 31/08/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The registered manager should ensure that that home’s medication training for staff includes a recorded assessment of competency for undertaking the role of administering medication. The registered manager should ensure that daily records are kept of all activities offered to residents, both mornings and afternoons. The registered provider should ensure that at least 50 of care staff are trained to NVQ level 2 or equivalent. 2. 3. OP12 OP28 Mansion House DS0000017878.V308932.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mansion House DS0000017878.V308932.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!