Inspection on 22/06/07 for McAuley Mount

This inspection was carried out on 22nd June 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

McAuley Mount 22/02/06

McAuley Mount 19/10/05

McAuley Mount 01/12/04

McAuley Mount 07/06/04

McAuley Mount 26/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE McAuley Mount Padiham Road Burnley Lancashire BB12 6TG Lead Inspector Jennifer Dunkeld Unannounced Inspection 10:00 22nd June 2007 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 McAuley Mount DS0000009511.V334504.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. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service McAuley Mount Address Padiham Road Burnley Lancashire BB12 6TG 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) 01282 438071 01282 431502 The Institute Of Our Lady Of Mercy vacant post Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: McAuley Mount is a two-storey purpose built care home situated in its own grounds. The home is owned and run by the Roman Catholic Order of the Institute of Our Lady of Mercy. The grounds/gardens are attractive, well maintained and accessible to the residents. The home is furnished and decorated to a high standard. The residents’ accommodation includes flats, which consist of a single en-suite bedroom, living room and kitchenette; single en-suite bedrooms and 2 single rooms without en-suite facilities. A passenger lift provides access between the two floors. The philosophy of care is underpinned by the Roman Catholic faith, Mass is held on a daily basis in the home’s Chapel. The main aim of the home is to provide high quality care for older people, both male and female, who feel comfortable and supported in an environment where the Christian values and lifestyle are paramount. Residents’ do not have to follow the Catholic faith and are free to choose their own lifestyle; everyone is welcome in the Chapel. Staff are available, to provide assistance with personal care and support, in response to individual needs/wishes. Various activities such as a weekly quizzes and bingo are available. The current weekly fees are £365.20 to £374 based on the assessed care needs of the individual. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has been inspected against the National Minimum Standards for older people introduced in April 2002. Prior to the inspection residents and their relatives were invited to take part in a written survey. A total of 12 surveys were returned, reflecting that people are well cared for at McAuley Mount. Comments included: “Excellent care” “Very good food” “Carers always courteous and respectful” “Prompt attention when needed” “My mother is treat with dignity at all times” and “ The home is just great, everyone is very caring, it must be the best home in the area” The inspection was unannounced in that the service providers, staff, the people living in the home and the manager did not know it was going to take place. This inspection commenced on 22/6/07 and was over a 2 day period lasting for 7.45-hour and looked at various aspects of care. In the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small group of residents. All records relating to these individuals are examined, along with the rooms they occupy in the home. Residents are invited to discuss their experiences of the home with the inspector; this is not to the exclusion of the other residents who contributed in many ways. This inspection included discussion with 10 of the current 22 residents, 4 members of staff, the Area manager and the homes manager in addition to viewing the home’s required written information such as the administration of medication records. The residents written plans of care were also viewed for 3 people as part of the ‘Tracking Process’. The plan of care is a document outlining the needs of the individual resident and how these are to be met. The plans of care generally cover all aspects of the individual’s life including health, personal care and social activities. Thereby ensuring people are content in the care they receive. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 6 The residents the inspectors spoke with were very happy with life at McAuley Mount. The staff stated they enjoyed their work at McAuley Mount and spoke to the inspector in a professional manner about the residents. They were also full of praise for Tracey the manager. Further information was gained from a Pre Inspection Questionnaire completed by Tracey the manager. This information included details of staff training, policies and procedures and how the management team ensure people receive the care they need. What the service does well: This home aims to provide good quality care and support for current and future residents. The management team were cooperative in their approach to the inspection process. The home was being well run with some changes being instigated by the new manager, such as an increase in staffing to ensure people’s needs are fully met. McAuley Mount had a very welcoming, tranquil, supportive and friendly atmosphere. The home was pleasantly decorated, the furnishings and fittings were of a very good standard; the residents said they liked the accommodation provided. The home was very clean and had no unpleasant odours. The people spoken with were full of praise about the care they receive. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 7 The completed questionnaires received from the residents and/or their family were full of praise and reflected; • • • • • All All All All All respondents said that they were happy with the overall care provided. respondents said that they liked living at the home. respondents said that they felt well cared for. the respondents said that their privacy was respected all of the time. the respondents said that the home provided suitable activities. Additional comments were received and these included: “My mother is very happy and content. She is very well cared for and understood as an individual.” “Excellent meals” “Staff are most welcoming and courteous” People were getting support with medical and health care, such as seeing the Doctor or attending hospital appointments. They were generally being encouraged as far as possible, to make their own decisions and choices about things, which affected them. Staff training and development was ongoing. The residents appreciated the care and attention provided by the staff and relationships between everyone in the home were good. The home was well maintained and health and safety matters were being appropriately managed, for the benefit of the residents, staff and visitors. What has improved since the last inspection? What they could do better: McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 8 Whilst the care plans seen as part of this inspection, identified the needs of the individual they did not always reflect the best way of meeting the need. For example one resident no longer felt able to go out alone for personal shopping, the plan of care identified that staff will get the personal shopping. It might have been a better option to offer staff to accompany the resident to make his/her own purchases. Thereby maintaining some independence. The care plans did not contain any information about the resident’s life prior to living at McAuley Mount. Such information can be important in understanding the individual and provide a topic of conversation with the individual concerned. There was no evidence of people’s medical history contained in the Care Plan, which could lead to the person’s conditions not being understood or met. There was some evidence of risk assessments on the care plan file for each resident. However there have been occasions when a quick solution has been identified in response to an incident. For example one resident fell while the cleaner was cleaning her room. The decision was made to ask residents to leave their room while the cleaner is carrying out her duties. It may have been better to carry out a risk assessment for people who would prefer to stay in their room. A consistent safe method of administering medication to people at the home needs to be adopted to ensure that people receive their medication as prescribed. When the above topics were discussed with the homes manager she immediately agreed to look into them for the benefit of the people who live at McAuley Mount. 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. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 9 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 McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 10 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): Standard 3 (Not standard 6 as this home does not offer intermediate care.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People do not move to live at McAuley Mount without their needs being assessed and assured that they will be met. EVIDENCE: There are informative and comprehensive details recorded about what the home provides and how this will be achieved. People new to McAuley Mount and their relatives are provided with opportunities to visit the home and allow them to make an informed decision. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 11 There is an intention to make sure people’s individual needs are clearly assessed and risks identified. From the initial assessments, care plans are developed reflecting how the person’s needs are to be met. The assessments were seen for 3 people who were part of the “tracking process” Each person living at McAuley Mount has a written contract on the terms and conditions that apply to their placement in the home. The completed questionnaires received from the people who live at McAuley Mount reflect that they were able to choose this home indeed people commented during the inspection that they feel they were lucky to live in this lovely home. One resident said “ I am so lucky to live here it must be the best home” another said’ “We are so well looked after, the staff are very kind and patient.” During the inspection a caller asked about a relative becoming a resident and the process was explained including the ‘need to carry out an assessment of the persons needs to make sure we are able to meet the needs’. This home does not offer intermediate care. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People benefit from living in a home where their needs and aspirations are generally met EVIDENCE: Peoples changing needs are identified as part of their care plan. The care plans are clearly written and explain the support the person needs in detail. For example one plan of care reflects that the person needs support with dressing. One carer is to prompt and supervise and only assist when necessary to enable the person to have as much independence as possible. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 13 Care plans based upon individual need are in place and it was seen that a person’s religious, cultural and relationship needs could be met. Care plans outline how changing needs are to be met however there is a need to ensure that the identified method is the one that the resident would choose for himself or herself. For example one resident no longer felt able to go out alone for personal shopping, rather than arrange for staff to do the shopping it might have enhanced the persons independence to offer a member of staff to occasionally escort the person to do their own shopping. When a person has a minimal need for staff support for personal care and spends the majority of time in their own room, there is a need to ensure the person is offered staff time to talk, to prevent the individuals from becoming isolated. Various health related policies and guidelines were available. Records indicated residents were generally receiving attention from health care professionals and that general health was being monitored, this was confirmed in discussion with residents and staff. Records included the dates and outcome of GP/District Nurse visits. The residents confirmed that they are always cared for with respect and their privacy and dignity is upheld. Comments included: ‘The staff are always polite and courteous’ and ‘this is a good home we are so well cared for, there can’t be anywhere better’ Diary notes are maintained to record the persons care needs on a daily basis or as necessary. However sometimes there is no evidence of the entry being followed up. For example one person’s notes reflect: ‘27/4/07 Sacrum is red and sore. Sheepskin ordered advised the person to walk around hourly to relieve pressure.’ There are no further entries to show that this advice was followed up on subsequent days. Medication on the first day of this inspection was being administered appropriately and the record signed at the time of administration ensuring that people receive the correct medication. However on the second day of this inspection it was noticed that medication was being put in a number of unnamed pots to take to threee individuals. The safest practice is to take the medication to the person in the container it is prescribed in to ensure the correct person receives the stated dose. The manager has agreed to ensure best practice. Medication and records looked at as part of case tracking; were found to be in order. Storage was good. All senior staff with responsibilities for medication had attended accredited training, or were due to receive training. Policies and McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 14 procedures were in place covering matters such as administration of medication, record keeping, self medicating, ordering and prescriptions. People who wish to self medicate are enabled to do so following a risk assessment. People have signed a Medication Declaration form outlining their wishes in relation to the administration of their medication. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 15 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): Standards 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. People benefit from living in a home where they are generally content in the care and support they receive EVIDENCE: The homes activity record reflects the following are periodically available: Watching DVDs Quoits Movement to Music Entertainers Sing-a –long Bing Walks in the garden McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 16 Walks in the garden are apparently enjoyed by a number of residents. This was evident from speaking with the residents themselves. A completed survey received from one relative stated there ’is a need for more escorted walks in the garden’ and another commented ‘Need to take people out to the shops’ The residents commented that the food was good. Indeed all the completed surveys received from relatives and the residents themselves made positive comments about the meals. Comments included: ‘the food is excellent’ ‘we are so well fed’ ‘It’s very good food’ and ‘We can have what we want within reason’ A sample lunchtime meal was taken as part of the inspection, during which it was noted that the tables were well laid with tablecloths, place mats, napkins, condiments and appropriate cutlery and dishes. The dining room had a stylish homely appearance. Staff offered support in a dignified manner. At the end of the meal tea and coffee were available and people were consulted as to what they would like for their tea. There were 2 options but if someone wanted something else it was available. One member of care staff said ‘I have known there to be 10 different meals served at teatime, to meet the wishes of the residents.’ People are generally enabled to have choice and control over their daily life. There appears to be a need to ensure that decisions made to maintain the health and safety of one person isn’t seen as the best practice for all. For example following a fall while a cleaner was cleaning the room of one resident, it was decided that it would be best if all residents were asked to leave their room while it was cleaned. A better practice would be to carry out a risk assessment for each individual and take into account his or her personal wishes. Some people enjoy talking with the cleaner while she carries out her duties. Care plans in addition to the physical needs of people, reflected their cultural and religious needs. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from living in a safe environment where they are protected and their opinion is all-important. EVIDENCE: There had not been any complaints made at the home or to the Commission for Social Care Inspection. The residents spoken with were keen to emphasise they had no complaints, but they were aware of the complaints procedure. The procedure for making complaints was in the homes guide and on display in the entrance hallway. The procedure was seen to include all the necessary details and contact information. Good policies and procedures were in place for dealing with complaints, including investigations. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 18 The homes protection/abuse policies included information based upon the ‘No Secrets ’ guidance, Procedures for reporting allegations, suspicions or incidents of abuse were seen. The completed surveys received from the residents and/relatives reflected that people knew how to complain but had never had the need to do so. Some staff had covered protection and abuse matters as part of NVQ (National Vocational Qualifications) training. An in-house training session on protection and abuse had been arranged for earlier in the year but the trainer forgot to attend. A new date has been rescheduled. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The resident’s benefit from living in a clean, hygienic and pleasant environment EVIDENCE: The home was found to be clean and was free from unpleasant smells. The laundry was suitably located and included appropriate washing equipment and facilities. The domestic staff had completed infection control training. The residents spoken with said they were happy with the accommodation provided at McAuley Mount and expressed an appreciation of the garden and grounds. A bench had been provided half way up the drive, so the residents McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 20 could have a rest when walking home. Handrails had been provided next to outside paths. Records were seen of ongoing maintenance and proposed refurbishment. The lounges and dining room were attractively furnished and provided pleasant living areas for the residents. The large conservatory had satellite television, a music system and tea and coffee making facilities. The homes Chapel provided for quiet reflection as well as the daily morning services. The self closing devices on some of the doors leading to the flats need adjustment as they closed very quickly and could be a hazard to the occupant when entering their room. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 21 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): Standards 27,28,29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a home where they are cared for by staff that are competent to do so. EVIDENCE: Residents spoken with were complimentary about the staff team. Comments included: ‘The staff are great’ ‘The staff are all very caring’ ‘The staff are so kind, they are all so good’ A relative stated, ‘The home needs more staff’ There had recently been recognition by the homes management team of the need for more staffing ‘across the board’. This was partly due to the changing needs of the individual residents. Recruitment had taken place and appropriate McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 22 checks have been taken including Criminal Record Bureau disclosures to ensure the right type of people are employed to meet people’s needs. The 4 staff files viewed contained the relevant information including an application form, 2 written references, Criminal Record Bureau clearances, interview questions and interview notes, induction record and records of training. New/unqualified staff were being supported to start NVQ training as a matter of course. Training records showed staff development was ongoing. Copy certificates were available on staff files. Discussions with staff confirmed various training courses were on offer and staff meetings were being held. The manager had recognised the need to increase the frequency of formal staff supervision to ensure training needs are identified and staff feel supported in offering a good standard of care. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 23 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): Standards 31,33,35 and 38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents’ benefit from living in a home that is well managed ensuring that people are well cared for. EVIDENCE: A fire drill was held on the second day of this inspection, to ensure that two new members of staff were fully aware of their role in case of fire. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 24 The atmosphere in McAuley Mount was welcoming, tranquil, friendly and supportive. Relationships between the residents, management and staff were good. The residents spoken with expressed an appreciation of the management team and the Institute of Our Lady of Mercy. The manager is relatively new to the home and not yet registered with the Commission for Social Care Inspection. She has a number of years experience in care home management and this was evident by the manner in which she has instigated changes with the agreement of the residents and staff. She has held a coffee morning for all residents, their relatives and the staff, where she introduced herself and listened to people’s views and opinions. This is something she intends to do again. There is recognition of the need for the manager to be seen on a regular basis by the residents, as this is where their feeling of security comes from. The comments received from the residents and their relatives were positive about the management of the home and included: ‘This is a well run home’ ‘This must be the best home in the area’ ‘The management and staff work hard to provide such a pleasant home’ People are encouraged and supported to look after their own money, so enabling them to maintain their independence. However there are some people who require the support of the home. Where this is the case a record of all money held and any transactions are maintained. The homes new record has been designed to give greater detail and includes the need for two signatures for all transactions. The management recognises Some people do need help to manage their money, but this support should not override their right to access their money and decide how to spend it. The manager is aware of the different cultural needs of the people who use the service and makes sure care is provided in a way that meets the person’s wishes and beliefs. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 25 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 26 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 OP7 Standard Regulation 12(2) Requirement Timescale for action 31/07/07 2 OP12 12(2) 3 OP9 13(2) 4 OP19 13(4)(a) The registered person must ensure care plans identify the agreed way of meeting an individuals needs. The registered provider must 31/07/07 ensure residents are enabled to make choices about when to use their bedroom. This must only be restricted within a risk assessment framework and explained to the resident The registered person must 31/07/07 ensure that there is a consistent safe method of administering medication to individuals within the home. The registered person must 31/07/07 ensure that the self closing devices on bedroom doors are adjusted to ensure doors close securely but do not present a hazard to the occupant. McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 McAuley Mount DS0000009511.V334504.R01.S.doc Version 5.2 Page 29 - 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!