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Inspection on 05/06/06 for Melbourne House Nursing Home

Also see our care home review for Melbourne House Nursing Home for more information

This inspection was carried out on 5th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A kind and caring ethos was prevalent throughout the home. Staff were observed to be kind and considerate to service users whilst attending to their needs. Service users spoken with sated that they were happy with care received and life within the home. One service user spoken with stated that they felt this was their home and they were happy and settled. Staff spokenwith were able to discuss service users needs and how equality and diversity is maintained in the home.

What has improved since the last inspection?

Care plans have improved when hand written to ensure service users whole person needs are fully addressed and personal choices and preferences are noted. Reviews have improved ensuring service users needs are fully met. Risk assessments have continued to develop working towards ensuring service users are protected. The cook and several other staff have undertaken a food hygiene course ensuring service users are protected. There was evidence to demonstrate that 18 members of staff have attained a criminal record check, working towards ensuring service users are safe. Several service users rooms have been redecorated ensuring a comfortable environment for service users. The manager has been allocated supernumerary hours ensuring she has more time to carry out her job role.

What the care home could do better:

Whilst it is acknowledged that hand written care plans have improved further development with regards to the computerised and pre-printed care plans is required to ensure holistic needs are addressed as well as service users personal choices and preferences, thus ensuring their needs are fully met. Risk assessments need continued improvement to ensure all highlighted risks are identified and a management plan is available to ensure service users are fully protected. Medication policies and procedures are required to be addressed to ensure the safety of service users. Evidence to demonstrate that all staff employed have criminal record bureau checks in place ensuring service users are fully protected. Registered nurses personal identification numbers are to be checked now and periodically to ensure they are current to protect service users. Staff personnel files are required to have relevant documentation to ensure service users are protected. Up to date quality assurance data is required for inspection evidencing the home is run in the best interest of service users.Evidence is required with regards to ensuring service users and staff health safety and welfare are maintained in regards to the mains electric testing, water temperatures, the fire alarm and emergency light testing.

CARE HOMES FOR OLDER PEOPLE Melbourne House Care Home Aspley Lane Aspley Nottingham NG8 5RU Lead Inspector Karmon Hawley Key Unannounced Inspection 5th June 2006 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 Melbourne House Care Home DS0000026453.V288149.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. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Melbourne House Care Home Address Aspley Lane Aspley Nottingham NG8 5RU 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) 0115 9294787 0115 9294787 Eastgate Limited Mrs Janice Ann Cooper-Brown Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Terminally ill (2) of places Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the total number of beds a maximum of 2 beds may be used for the category of TI Within the total number of beds 1 bed can be used for a named service user aged 44 years Date of last inspection Brief Description of the Service: Melbourne House is a purpose built two storey building providing care for up to 38 older people with 2 beds registered for people with terminal illness. There are 3 lounges and a large dinning room providing ample space. The majority of bedrooms are single and a number are ensuite. There is a lift to the second floor and the building is wheelchair accessible. The building is set within its own grounds, which are accessible to service users, it is also close to local amenities in Aspley, which is on the main bus route into the city of Nottingham. The current weekly fees are as follows: nursing fees local authority Nottingham city council £392, Nottingham county council £426. Private nursing £445. MAY Scheme £426-476. High dependency residential local authority Nottingham City Council £307.96. Nottingham County Council £319. Private £350. Residential Nottingham City Council £272.58. Nottingham County Council £277. Private £325. For ensuite rooms there is an extra £20 charge. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. One inspector undertook the site visit over course of four and a half hours. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of four randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Six service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The manager was not available during this inspection, the nurse in charge stated that she had left all required documentation available that may be required, however unfortunately not all documentation needed could be located at this time. Therefore whilst it is acknowledged that this information may be available it was not on the day of the site visit, which the main body of this report is based upon. The provider was spoken with who assured the inspector that all required information would be forwarded to the inspector on her return. The nursing in charge and the administrator assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: A kind and caring ethos was prevalent throughout the home. Staff were observed to be kind and considerate to service users whilst attending to their needs. Service users spoken with sated that they were happy with care received and life within the home. One service user spoken with stated that they felt this was their home and they were happy and settled. Staff spoken Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 6 with were able to discuss service users needs and how equality and diversity is maintained in the home. What has improved since the last inspection? What they could do better: Whilst it is acknowledged that hand written care plans have improved further development with regards to the computerised and pre-printed care plans is required to ensure holistic needs are addressed as well as service users personal choices and preferences, thus ensuring their needs are fully met. Risk assessments need continued improvement to ensure all highlighted risks are identified and a management plan is available to ensure service users are fully protected. Medication policies and procedures are required to be addressed to ensure the safety of service users. Evidence to demonstrate that all staff employed have criminal record bureau checks in place ensuring service users are fully protected. Registered nurses personal identification numbers are to be checked now and periodically to ensure they are current to protect service users. Staff personnel files are required to have relevant documentation to ensure service users are protected. Up to date quality assurance data is required for inspection evidencing the home is run in the best interest of service users. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 7 Evidence is required with regards to ensuring service users and staff health safety and welfare are maintained in regards to the mains electric testing, water temperatures, the fire alarm and emergency light testing. 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. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 8 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 Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 9 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 The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users may be assured their needs will be assessed and met prior to admission. EVIDENCE: The manager carries out assessments in the community prior to service users entering the home. The assessment covers the requirements of the standard. Service users and relatives may visit the home prior to admission to ensure they are able to make an informed choice. Melbourne House Care Home DS0000026453.V288149.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 The quality rating for this outcome area is poor this judgement was made using evidence available including a visit to the service. Service users health, personal and social care needs are set out in a plan of care, however further development is required to ensure service users needs are fully met. Service users may be placed at a degree of risk due to the continued need of risk assessments and management plans required for all highlighted risks. Service users health care needs are fully met. Service users are not protected by the homes medication policies and procedures. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Four service users care files were observed which reflected that assessments with regards to the activities of daily living, pressure areas, manual handling and nutrition are undertaken to form the basis of the plan of care. There was evidence available to demonstrate that service users and relatives had been involved in the care planning processes and reviews. Reviews taking place Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 11 were service user focused and reflected care and condition. Care plans in place were of both a computerised pre prepared nature and handwritten. The computerised care plan did not fully address complex needs and reflect individual care in a holistic approach whereas the hand written ones addressed individual needs choices and preferences. Risk assessments were in place for a number of highlighted risks, however were not in place for service users using bedrails and those experiencing challenging behaviour. Progress notes were in place and highlighted significant events. There was evidence available to demonstrate that specialist services and the multidisciplinary team are accessed as required. Several professionals were visiting the home on the day of the site visit and a good rapport was evident. The medication records of those service users cased tracked were observed. One service users prescription chart had handwritten entries and two signatures had not been obtained to demonstrate these had been checked and were correct. There was no evidence to demonstrate that medicines are checked into the building. There were gaps in the signing of medication administered. There were discrepancies in the service users prescription chart and that obtained from the pharmacist. No fridge or room temperatures were available. Returns are currently sent to the pharmacy, evidence was available to demonstrate this. Signage was displayed to demonstrate the storage of oxygen. The nurse in charge stated that staff are instructed on maintaining service users privacy and dignity at all times. Staff spoken with stated they knock on service users doors prior to entering and they also use signs which state care is in progress so people do not enter unless permission is given. If service users require a private area this is usually within their own rooms, the conservatory or the office. Service users spoken with stated that staff were kind, considerate and respectful at all times and that their privacy was maintained. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 12 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 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users are enabled to experience a life style that meets their expectation and satisfies their needs. Service users are enabled to maintain contact with relevant others. Service users are enabled to exercise choice and control over their lives. Service users receive a wholesome appealing diet in pleasing surroundings EVIDENCE: An activities coordinator is employed in the home. Service users undergo social assessments, which reflected individual choices and preferences and records were available to demonstrate that service users had participated in activities if they wished. There were various resources available around the home. Service users spoken with substantiated that activities were available and were enjoyable, some joined in whereas other chose not to. Cultural, religious and recreational needs are noted within the plan of care and the nurse in charge stated that holy communion is offered on a weekly basis, service users may also attend church in the community should they wish. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 13 Visitors are welcomed into the home, one service user stated that their visitors are made welcome when they visit and they may be entertained in their room should it be desired. The visitor’s policy is discussed prior to admission and is displayed in the main entrance. The routine of the home is stated to be flexible and service users may choose how they spend the day. Service users spoken with substantiated this. If able service users maintain control of finances, however there are facilities available to assist this if needed. Although advocates are not used at present they have been used in the past and staff were aware of how these may be accessed should the need arise again. Service users are able to bring in personal possession to make their rooms more homely and one service user spoken with substantiated this and expressed how pleased they were to bring in their own belongings. Mail is received unopened or it is given to relatives if considered necessary. A telephone is available for service users use in the office and there are telephone points in each room should a service user require an individual line installed. The nurse in charge stated that equality and diversity is recognised within the home and the ethos of the home was to ensure this is embedded into practice by ensuring individuality is respected, service users are offered choices and their specific needs are met. Staff spoken with were able to discuss the concepts of equality and diversity and how this is facilitated within the home. On observation the kitchen was extremely clean, tidy and well organised. All cleaning plans and temperature testing were recorded and up to date. The menu demonstrated that choice was available and a wholesome and appealing diet offered. Service users when spoken with stated that food was at a good standard and they had a choice at meals. Service users are assisted with meals as required in a dignified manner and special diets are also catered for. All service users undergo a nutritional risk assessment to ensure needs are met with this regards. The cook has now obtained an up to date food hygiene certificate. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 14 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 The quality rating for this outcome area is poor this judgement was made using evidence available including a visit to the service. Service users and relevant others may be assured complaints will be listened to, taken seriously and acted upon. Due to the lack of evidence available with regards to criminal record checks and the lack of official training in adult protection service users safety may be compromised. EVIDENCE: Appropriate policies and procedures are in place with regards to complaints. One complaint has been received since the previous inspection with regards to staff attitudes and care received; this had been investigated by the manager and resolved. Staff spoken with were able to discuss how they would deal with a complaint should it be received. Service users spoken with were happy with care received and expressed no complaints. On speaking with staff they stated they had had discussions in regards to adult protection and they were able to discuss relevant issues with the inspector, however there were no records available to substantiate that official training had taken place. On examination of criminal record bureau checks, not all staff had these in place. The administrator stated these had all been done and invoices were produced as evidence for 18 staff, however there was no evidence available to substantiate the remaining 10 staff had criminal record checks in place, therefore the administrator contacted the agency who had Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 15 carried these out and information required is to be forwarded to the Commission for Social Care Inspection to substantiate these checks have taken place. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 16 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 The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users live in a safe satisfactory maintained environment, which is clean, pleasant and hygienic. EVIDENCE: A maintenance man and a gardener are employed. Several service users rooms have been redecorated since the previous inspection. There was evidence available to demonstrate that regular maintenance is undertaken in the home. The garden was well kept and offered a pleasant environment for service users and relevant others. Relevant equipment and adaptations were noted to be available. There are three lounges, a conservatory, separate dinning room and the entrance room to provide ample seating within the home. Doors with the exception to the main door and laundry door are linked to an alarm system. On the day of the inspection these alarms were set off by a service user who was leaving the home, the staff on duty responded quickly. All heating within the home is supplied under floor or ceiling. Window Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 17 restrictors are in place. There are further health and safety issues discussed in standard 38. Adequate domestic staff are employed to maintain hygiene standards, the home was clean and tidy on the day of the site visit. Service users rooms were personalised and relevant aids and equipment were noted to be available. Some rooms are ensuite and there are ample washing and toilet facilities available. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 18 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 The quality rating for this outcome area is poor this judgement was made using evidence available including a visit to the service. The number and skill mix of staff meets service users needs. Staff are working towards ensuring service users are in safe hands at all times, this will be improved upon once the induction programme has been improved and staff have finished the national vocational qualification. Services users at present are not fully supported and protected by the homes recruitment and selection policies and practices. Whilst it is acknowledged that staff were able to discuss areas with regards to training due to the deficits in mandatory training staff are not fully trained to do their jobs. EVIDENCE: The staff rota was observed and demonstrated that sufficient staff are employed at present. On completing the duty rota the skill mix of staff is taken into consideration. On speaking with service users they stated that staff were available to meet their needs. Staff spoken with stated there were sufficient staff available, however on infrequent occasions due to sickness this may not be so. Two staff currently have attained their National Vocational Qualification (NVQ) level two in care and a further 9 staff are working towards this qualification. The induction programme is still unchanged since the previous inspection. Four staff personal files were observed these did not contain all the required documentation as required. Evidence to demonstrate that 21 staff have Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 19 attained criminal record bureau checks was available, however there was 10 members of staff where evidence was not available, therefore the administrator contacted the agency who had completed these for confirmation so this may be forwarded to the commission. Registered nurse personal identification numbers were available, however with the exception of one, there was no evidence to demonstrate that these had been checked to ensure they are current. A staffing matrix is maintained which demonstrates that mandatory training is delivered, however there were deficits in health and safety, adult protection dementia care, first aid and manual handling. The home continues to follows a basic induction programme, although the manager is looking to improving this to meet with requirements. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 20 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): The quality rating for this outcome area is poor this judgement was made using evidence available including a visit to the service. Service users live in a home which is run and managed by a person fit to be in charge who is of good character and able to discharge her responsibilities. There was a lack of evidence available to demonstrate that the home is run in the best interests of service users. Service users personal finances may not be fully safeguarded. The health safety and welfare of service users and staff may be compromised due to the noted deficits. EVIDENCE: The manager is a registered nurse and remains up to date in her practices by attending various courses and training events. She has been employed by the Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 21 in the home for ten and a half years, five and a half of which have been as the manager. She has completed an introduction to managing and is now looking into funding with regards to the National Vocational Qualification Registered Managers Award. Staff spoken with stated that the manager was approachable and supportive. Service users spoken with had no concerns with regards to the management of the home. The manager now has more allocated time on a supernumerary basis to ensure time is dedicated to her specific job role. Four service users personal allowances were checked against individual accounting sheets. Three of these were correct, whereas the other had more money available than recorded. Two signatures were available for each transaction and if obtained receipts were kept on file. The manager or proprietor is not responsible for any individual’s money. Quality assurance questionnaires are sent to service users on an annual basis, which are received by the proprietor and evaluated, these are then passed to the manager to address any negative issues. Recent copies of these were not available for inspection, however questionnaire that had been completed in 2002 were on file. Service users and relatives are free to approach the manager should they have any issues they wish to discuss. Several Commission for Social Care inspection questionnaires had been completed and due to be returned. Servicing and maintenance records were observed, the main electrical testing certificate, which was not available, this is to be forwarded to the commission for social care inspection. The lift has been serviced, however the certificate has not been sent to the home, a copy of this is to be forwarded to the Commission for Social Care Inspection. The homes insurance certificate was current until 6th June 2006; a copy of the new certificate is to be forwarded to the Commission for Social Care Inspection. Fire alarm testing had not been carried out on a weekly basis, emergency lighting had not been carried out on a monthly basis and water temperatures were not available. Staff training is lacking in several mandatory areas, as are staff personal files. There were inconsistencies in regards to the medication procedures. Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 22 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 1 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 1 Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1) Requirement Continue to work towards personalising plans of care to ensure a holistic approach is developed thus ensuring equality and diversity is fully recognised and service users needs are fully met. Risk assessments and management plans are required to continue to develop to ensure service users are fully protected. risk. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in to the home. This is an outstanding requirement and must be addressed to avoid enforcement action. All staff employed are required to have Criminal Records Disclosure Checks in place. Evidence to substantiate this has taken place is required to be forwarded to the Commission for Social Care Inspection. To ensure service users are DS0000026453.V288149.R01.S.doc Timescale for action 05/08/06 2. OP7 13(4c) 05/07/08 3. OP9 13(2) 05/06/06 4 OP29 19 (1) 12/06/06 5. OP29 18(1a) 05/06/06 Page 24 Melbourne House Care Home Version 5.2 6. 7 OP29 OP30 19(1,b) 18(1,c,I) 8 9. OP33 OP37 24(2) 17(3a) Sch 4 protected the validity of registered nurses personal identification numbers are to checks as being current and measures are to be put into place to ensure this is done on a regular basis. All staff employed are required to have documentation as listed in schedule two on file. Staff are to be trained in all mandatory areas to ensure they have the required skill and knowledge to fully meet service users needs. Up to date Quality assurance data is to be available for inspection Records with regards to maintaining health and safety of service users are to be maintained and available for inspection. 05/08/06 05/08/06 05/08/06 17/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Melbourne House Care Home DS0000026453.V288149.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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