Inspection on 27/06/06 for Mimosa

This inspection was carried out on 27th 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mimosa 29/08/07

Mimosa 19/12/05

Mimosa 20/06/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Mimosa 4 Shirley Road Hanley Stoke on Trent Staffordshire ST1 4DT Lead Inspector Jane Capron Key Unannounced Inspection 27 June 2006 8:45 Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 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 Mimosa DS0000064017.V300568.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mimosa Address 4 Shirley Road Hanley Stoke on Trent Staffordshire ST1 4DT 01782 280838 01782 269187 chris@delamcare.co.uk 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) Delam Care Ltd Mrs Pauline Adams Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (5) of places Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Mimosa is a residential care home providing 24 hour care for five people with a learning disability and mental health concerns. The accommodation provides for one double and three single bedrooms. The home has a lounge and separate dining room and there is a small garden area at the rear of the property. The home has bathing and shower facilities – the bathroom being upstairs and the shower downstairs. There is no on site parking. The home shares the use of two people carriers with five other care homes in the vicinity owned by the same company. The home is located close to Hanley park and in the area there are some local shops. A short distance away there are other amenities such as medical services, a hairdresser and leisure facilities. Residents can attend a local college for a number of sessions a week and join with service users from the neighbouring care home to go out on trips and on holiday. The home offers some activities at the home. Service users are involved in day to day activities associated with running the home including ensuring their bedrooms are tidy and clean and with washing up, laying the table and shopping. The home has a staffing level of one care staff on at any time. The Care Manager has the responsibility for the care home next door. The current fees are from to £425 -£491 per week (June 2006). Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took approximately four and a half hours. The inspection included discussions with the Care Manager, the deputy manager and four of the five residents. A sample of documents relating to residents care needs was examined. The arrangement for administrating medication was looked at as well as the home’s procedures for recording and safeguarding residents’ finances. A sample of staff personnel files were looked at to check the home’s recruitment and selection procedures and to identify the training that staff had received. The menus were examined and the arrangements for Health and safety were considered including looking at the arrangements the home had made for fire safety. All the bedrooms were looked at as well as the communal rooms. The home had received no complaints over the last twelve months and there had been no additional visits made to the home. What the service does well: Residents said they liked living at the home and said that they got on well with each other and with the staff. They said that staff respected their privacy and provided them with any support they needed. The home had support plans in place that identified the needs of the residents and showed what staff needed to do to meet the residents’ needs. Residents said they met with staff to discuss their care. Residents confirmed that they were provided with choice over their lifestyle. One resident said they had chosen to go to college every day whilst another said that they had chosen not to attend. The home’s routines were quite flexible. Residents could spent time in their bedrooms or in the communal areas. They could go to bed and get up when they wanted depending on their agreed schedules. They were involved in choosing the menus and were able to have an alternative if they did not like the meal on the menu. Residents said that they were involved in household tasks including meal preparation and with staff support to keep their bedrooms clean and tidy. The residents’ views were sought at resident meetings about such issues as meals, holidays and activities. Residents were aware of how to complain and said that staff listened to them and acted on any concerns they raised. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 6 The home was meeting the health care needs of the residents. Residents said that they attended for eye checks, dental checks and had their nails cut by the chiropodist. Those residents that needed it were receiving psychiatric services. The home was aware of the issues relating to the needs of an older resident who spend time in the morning reading the newspaper and had a rest in the afternoon. The staff had received induction training and had training in health and safety issues. What has improved since the last inspection? What they could do better: There were some areas that the home needed to address to ensure the home fully met the standards. The accommodation was generally of a satisfactory standard but this would be improved by one bed having a new mattress. In addition the toilet downstairs needed attention to remove the overflow pipe from being located over the hand washbasin. Whilst the home was ensuring the all staff had two references and a satisfactory CRB there were no documents on file to confirm the identity of staff and this needs to be addressed. These need to be provided to improve the level of protection for residents. The home had an action plan in place to bring the home up to the necessary fire standards and this must be completed as scheduled. Whilst staff were in the main undertaking the necessary Health and Safety training the home should ensure that staff had training in infection control. It was also recommended that the home look at providing information in formats more suitable for the residents and to look at ways that residents Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 7 could be more fully involved in the assessment of the quality of the service. Residents could also be more involved in aspects of running the home. It was also recommended that the home provide one fire training session a year from a fire specialist. 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. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there were no pre admission assessments on file there had been no admissions for several years and the home had developed internal assessments that identified the needs of the residents. The home was able to support the current residents to have their needs met. The rights and responsibilities of the residents were identified in the contracts provided by the home. EVIDENCE: All the residents had lived at the home for many years except one resident who moved from a nearby home owned by the same company approximately two years ago. There were no original pre-assessments on file but there was evidence that the home had undertaken internal assessments and that the personal histories of the residents was on file. The home was able to meet the needs of the current residents. The home had developed satisfactory relationships with health care professionals and residents were supported to access the necessary healthcare services including mental health and general health. The staff had the knowledge of the residents to provide them with the support they needed to have their needs met. Staff were aware of any communication needs and appropriate interaction was observed between residents and staff. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 10 The home had provided residents with a contract that showed residents rights and responsibilities. These were not in use friendly format. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s care planning processes provides the necessary information for staff to be able to meet the needs of the residents. Risks are identified and the plans in place support residents to take reasonable risks and do not subject them to unnecessary restrictions. Residents are supported to make choices over their lifestyle and are provided with opportunities to participate in a range of tasks related to running the home. EVIDENCE: A sample of three resident files was examined. All had support plans in place that included residents’ general and healthcare needs, their need for personal support and their occupational, educational and social needs. These plans showed the actions needed by staff to support residents to have their needs met. The staff and the resident had completed internal reviews but not all files demonstrated that reviews were taking place with significant professionals. All residents had a key worker and residents were aware of the identity of their key worker. The plans were not in a user-friendly format. The home had developed a range of individual risk assessments. These covered such areas as accessing the community; managing medication, Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 12 making hot water and managing hot surfaces. These assessments were up to date and had been reviewed. Residents were provided with choices over their lifestyle. They said that they had breakfast when they got up and could decide what to do during the day. They said they could choose whether to go to college and whether to join in with organised activities. Residents could go to their bedroom at any time or could join other residents in the lounge. Some residents tended to watch their TVs in their bedroom whilst others preferred to watch in the lounge. The residents had the choice to go to a birthday party on the day after the inspection and one resident had decided not to go, preferring to stay at the home. Residents confirmed that staff supported them to choose clothes to buy. Residents also confirmed that they had menu meetings to plan the meals and that meals of their choice were on the menu. They also said that if they did not like a meal on the menu they could have an alternative. All of the residents needed support to manage their own money but discussions with residents confirmed that residents made choices over what to spend their money on. Residents participated in a range of tasks related to running the home. This included planning menus, doing the food shopping, going on a daily basis to buy bread and milk and being involved in keeping the home clean and tidy. All residents were involved in cleaning their bedrooms with the support of staff and in assisting with meal times through either helping with food preparation, laying and clearing the table and washing up. Residents also helped with gardening. Resident meetings were held monthly and records showed that issues such as meals, activities, household issues and staffing issues were discussed. There was some scope for residents to be more involved in influencing the development and running of the home. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ lifestyle is enriched through taking part in a range of educational and leisure opportunities both in the home and in the community. The home supports residents to maintain and develop appropriate relationships with friends and family. The home’s meals were based on residents’ choice and healthy eating, and took account of residents’ dietary needs. EVIDENCE: The residents had the opportunity to attend college and three residents have taken this option. One resident goes to college every day. Courses include art and drama, jewellery making, floristry and aromatherapy. One resident, who is older, chooses to remain at home and reads the newspaper, watches TV and has a rest in the afternoon as well as doing task around the home. All residents regularly access the community either independently, with other residents and with staff. They use community health care services; they go to the shops, a local pub and to the bank every week. Residents took part in activities within the home including baking, having a weekly cinema night and art and crafts. Residents had TVs and videos in their Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 14 bedrooms. The lounge had a TV, video and DVD facilities. The records also showed that residents had the opportunity to go out on some organised trips and they had recently been to Manchester Airport. The residents also had the opportunity to occasionally go to the theatre and to see musical groups. The home also occasionally went on picnics and several residents said they went to the park to play football and to go for a walk. All residents regularly went shopping either locally or into Hanley. The home organised a pub visit most weeks. Residents were encouraged to maintain and develop relationships with family and friends. Several of the residents visited friends in the care home nearby. The residents had developed positive relationships with the residents at the home next door and they joined together to celebrate social occasions and went on holiday together. The residents were due to go on holiday to Wales in the next few weeks. Residents fund their holidays themselves with residents paying for the accommodation and travelling costs and the home paying for the staffing. The home had shared access to two people carriers for which they contribute on a monthly basis. The homes’ routines were quite flexible. Residents could get up and go to bed when they wanted and could spend time in their bedroom of in the communal rooms. All bedrooms were lockable and one resident kept their roomed locked. Staff respect residents’ privacy and do not enter bedrooms without knocking and gaining the permission of the resident. Residents said that staff respected their privacy when helping them with personal care tasks. Residents liked the meals provided and said that they helped plan the menus and do the food shopping. Residents said that if they did not want a meal on the menu they could have an alternative. Examination of the menus showed that the home provided a varied menu and that the residents had three meals a day and that supper was provided. Breakfast was taken when residents got up and lunch tended to be a snack type meal such as sandwiches or something on toast followed by fruit or yoghurts. The main meal was at teatime and comprised of for example meat and vegetables followed by a pudding. A roast Sunday lunch was always provided. Residents assisted with the meal process either through helping to lay and clear the table, washing up or with preparing vegetables. The home was aware of residents’ dietary needs and based the menu on residents’ preferences and healthy eating. The home had one resident with diabetes and the home ensured that they received an appropriate diet. The home monitored residents’ weight. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support was provided in a manner that respected residents’ privacy and promoted their independence. The health needs of the residents were being met with evidence of multi disciplinary working taking place. The system for the administration of medication was good ensuring that the medication needs of the residents were met. EVIDENCE: The support plans fully identified the personal and health care needs of the residents. Speaking to the staff on duty confirmed that they were aware of residents’ health and personal care needs and how these were to be met. The home provided residents with the support to ensure their personal care needs were met. Support for hair care was being provided and residents were attending for eye and dental checks and attended the chiropodist. The staff assisted residents to shave daily. The home supported residents to attend for general and mental health care treatments. One resident confirmed he went for monthly injections and had regular check ups. The diabetic nurse was positive about the staff’s support for residents with diabetes and felt that the staff undertook effective liaison and supported residents to attend the diabetic clinic. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 16 The home had a procedure for the storage and administrating medication. All staff had received training in medication. Medication was being stored securely and the examination of a sample of records and medication showed that medication was being administered appropriately. The home maintained records of medication received and that returned to the pharmacy. The support plans included residents’ agreement for staff to administer medication. One resident self-medicated on a daily basis and an assessment was in place confirming the resident’s ability to do this safely. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure and whilst the procedure is not in a user-friendly format the residents feel any concerns are acted upon. The home’s adult protection procedures are providing residents with protection. EVIDENCE: The home had a complaints procedure and this was displayed n the hallway. Although this was not in a user-friendly format the residents knew how to complain and said that staff listened to them and sorted out any problems. The home had received no complaints. The home had a procedure in place for the prevention of abuse to vulnerable adults and records showed that staff had responded appropriately to a potential incident of abuse. Staff had received training in adult protection. The home had procedures in place to safeguard residents’ finances. A check of finances showed that the home was keeping accurate records and that receipts supported residents’ expenditure. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment provided residents with accommodation that was homely and domestic in style although there were some issues that needed to be addressed. The residents benefited from a home that was clean and hygienic and that had procedures in place to reduce the likelihood of infections spreading. EVIDENCE: The home was located in a property that was in keeping with the properties in the neighbourhood. There was a small front garden, that needed some tidying up and a larger rear garden with seating for the residents. The home was close to local shops and health care resources and was a twenty-minute walk away from Hanley shopping centre. The premises were suitable to meet the residents’ needs. The home had three single bedrooms all of a good size and one two-bedded room that provides screening. The residents in the twobedded room said that they were happy to share. Since the last inspection two bedrooms had been decorated and this had improved these rooms. Bedrooms had adequate storage facilities. One bed needed a new mattress. The home had a dining room, lounge and kitchen that were all domestic in style. The Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 19 stairs carpet had been replaced and there were plans for the dining room to be decorated. The home had a schedule in place for maintenance and renewal of fabric and decorations. The home had adequate bathing and showering facilities having a bathroom upstairs and a shower downstairs. The home had adequate toilet facilities but the toilet downstairs needed some attention as the overflow pipe was positioned to discharge over the hand washbasin. The home was clean and tidy throughout and the home had cleaning schedules in place. The home had a laundry that was shared with the home next door and was accessed through the garden. The laundry was able to meet the laundry needs of the residents. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels are adequate to meet the needs of the residents. The residents are benefiting from staff that are qualified and are supported to undertake their role and who are aware of residents’ needs. The home’s recruitment and selection procedures are generally safeguarding the residents. EVIDENCE: The home staffing levels allowed for one staff member to be on duty throughout the day and one staff member to sleep at the home at night. This level of staffing was adequate to support residents with low levels of dependency but could cause difficulties for residents to have staff support out of the home without prior planning. The Care Manager did provide support to enable the staff member to go out with residents. The care company provided some additional staff to support residents to attend college. The home had three staff that worked at the home permanently and other staff from other care homes that provided any additional support needed. The home had one staff qualified to NVQ level 2 and a further staff taking the qualification. The other staff member had obtained NVQ level 3 and was in the process of completing level 4. The staff member spoken to was well motivated and was knowledgeable about the individual needs of the residents. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 21 The home’s recruitment and selection procedures ensured that two references and a satisfactory CRB and POVA check were undertaken. There was not evidence on staff files that staff identity had been confirmed. Staff were subject to a probationary period and undertook induction training. Staff were provided with a contract of employment. The home training profiles identified the training that staff had undertaken. A sample of personnel files showed that staff had undertaken training relating to the care needs of the residents. This included mental health awareness and challenging behaviour. Staff would benefit from some training in person centred planning. Staff were supported to undertake their role. Staff meetings approximately every two months and staff received individual supervision approximately monthly. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents were benefiting from a home with a manager who was qualified and had the necessary knowledge and experience to lead the home. Whilst the home had some systems in place to review and monitor the quality of the service these should be further developed so that the views of the residents were more fully considered. The home was providing the residents with a home that was generally safe but the home did need to ensure that the fire safety action plan was completed on time. EVIDENCE: The Care Manager had worked at the home for approximately three years. She was suitably qualified and had the necessary knowledge and experience to lead the home. She had undertaken recent training. The home had some systems in place to review and monitor the quality of the service. These included audits of a range of environmental issues and checking of residents’ documentation. The systems did need more resident involvement Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 23 to ensure that their views underpinned the process and provided the necessary information to lead to improvements in the service. The home had a Health and Safety policy and a range of procedures in place to provide a safe working environment. The home maintained records relating to the servicing of equipment. The fire safety equipment was being checked with the fire alarm being tested weekly and the emergency lighting tested monthly. The home had recently been inspected by the fire service and this has identified some areas that needed to be addressed. The home had developed an action plan to address these and this must be adhered to ensure that the safety systems are fully in place. The home regularly checked the temperature of the freezer and fridge and due to the freezer temperatures being consistently high the home had requested the supplier to return to look into the problem. The home was also probing the temperature that food was cooked at. The home was safely storing hazardous substances. The home had covered the radiators in the bathing areas and all residents had been assessed as being able to mange hot surfaces in other areas. The home was keeping a record of accidents. Staff had completed Health and Safety training including moving and handling, food safety, first aid and fire but some staff needed to complete training in infection control. It is recommended that the home provide staff with fire training from a fire specialist once a year. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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 3 4. 5. Standard YA24 YA34 YA42 YA42 YA42 Regulation 16(2)(c) 19 Schedule 2 23(4)(c) 18(1)(c) 23(2)(c) Requirement To provide the identified bed with a new mattress. To ensure that records are held confirming staff’s identities To ensure that the fire action plan is completed as scheduled. To ensure that all staff have training in infection control. To ensure that the downstairs toilet overflow is altered so it does not discharge in the hand wash basin. Timescale for action 31/07/06 26/08/06 31/07/06 01/09/06 26/07/06 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 2 3 4 Refer to Standard YA5 YA5 YA8 YA5 & YA20 Good Practice Recommendations To develop person centred planning To undertake reviews involving significant professionals To look at ways of further involving residents in decisions relating to running the home. To develop information in a user-friendly format. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 26 5 YA42 To provide annual fire training by a fire specialist. Mimosa DS0000064017.V300568.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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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