Inspection on 22/06/06 for Mon Choisy

This inspection was carried out on 22nd June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mon Choisy 24/07/09

Mon Choisy 24/07/07

Mon Choisy 16/07/07

Mon Choisy 21/02/06

Mon Choisy 09/08/05

Mon Choisy 23/11/04

Mon Choisy 29/06/04

Mon Choisy 12/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Mon Choisy 128 Kennington Road Kennington Oxford OX1 5PE Lead Inspector Delia Styles Unannounced Inspection 22 June 2006 10:15 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 Mon Choisy DS0000013112.V299878.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. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mon Choisy Address 128 Kennington Road Kennington Oxford OX1 5PE 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) 01865 739223 enquiries@auditcare.com Mrs Ellen Audit Mrs Ellen Audit Care Home 28 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (28) of places Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 28. 21st February 2006 Date of last inspection Brief Description of the Service: The home is located near Oxford in the village of Kennington, close to shops and public transport facilities. The home is privately owned and managed and provides 24-hour support for a maximum of 28 residents; it does not provide nursing care but accesses appropriate external medical and nursing services to maintain the health of the residents living there. Mon Choisy is the larger of two homes owned by Mr & Mrs Audit in Kennington and shares a management structure and policies and procedures with its sister home, Kirlena House. It was opened in 1985 and extended in 2001. There are 22 single rooms and three double bedrooms with a wash hand basin in each. There are two assisted baths, five showers and ten WCs. The house itself is detached, with a patio area and sloped garden at the rear that can be accessed via pathways with handrails. Residents’ rooms are on two floors with stairs and lift access the first floor. The rear ground floor sun lounge overlooks the garden and there are further communal rooms – a separate dining room-cum-sitting room, a sitting room overlooking the front drive and a small internal sitting room. The kitchen caters for the residents of both homes. There is a laundry and further utility rooms in outbuildings at the rear of the home. The fees for this home range from £491 to £562 per week. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of Mon Choisy was an unannounced ‘Key Inspection’. The inspector arrived at the home at 10.15am and was in the service for 5 hours. The inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owners and manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. 17 residents’ surveys (comment cards) were received, six relatives’/visitors’ comment cards and three from general practitioners who provide medical care to residents in this home. The inspector looked at how well the service was meeting the standards set by the government and has, in this report, made judgements about the standard of the service. The inspector discussed her findings and recommendations with the home owner and registered manager, Mrs Audit, at the end of the inspection. The publication of this report is late due to the fact that the provider did not respond to the draft report within the 28-day timescale. What the service does well: The home provides care in a friendly and domestic-scale home in a large village setting. Residents and their relativess are pleased with the kindness and standard of care provided by staff. The home managers provide regular training and supervision meetings for staff, so that staff are clear about what standards are expected of them. The home owners/managers, Mr and Mrs Audit and Mrs Bradbury, are available to residents in the home on a daily basis, and take a personal interest in residents’ care and wellbeing. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 is not applicable - intermediate care is not provided. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. People who are admitted to this home have sufficient information about the services through their family or social services representatives. EVIDENCE: The home’s Statement of Purpose and Service User Guide outline what the home can and cannot provide. They are written in plain English and are easily understood. Each resident has a written contract of terms and conditions. The residents themselves or their advocates (if the resident is not competent to do so for themselves) sign the residents’ contracts. Comment cards received from residents showed that the majority of respondents were satisfied that they (or a relative acting on their behalf) had received a contract and sufficient information about the home before they went to live there. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 9 The assessment details for two residents were looked at – one for a recently admitted resident and one expected admission. This included information from care managers and other health and social care professionals. Basic information for staff was available to start writing care plans that will help care staff to give the residents the level of assistance and support they need. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home’s practices for meeting residents’ health and personal care needs are satisfactory and residents are treated with respect. EVIDENCE: The inspector looked at a sample of five residents’ care plans. There is evidence that care plans are regularly reviewed and updated. Most residents are unable to effectively contribute to their own care plans because of their level of physical or mental disability. The plans had been signed by next of kin, indicating that they had been read and agreed as appropriate plans of care for the person being looked after. The care records showed that there are appropriate medical reviews, and residents are treated promptly for acute medical problems – chest and urinary infections, etc - and district nurses visit to provide any occasional nursing care needed. However, there was little written evidence of the evaluation of car, ie whether the planned care has met the resident’s need effectively. More information about the social and psychological care needs of the residents should also be included. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 11 From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural backgrounds. Fifteen of the 18 residents who completed comment cards stated that they were always satisfied with the care and support they receive. Relatives’ and visitors’’ comment cards showed that they felt able to visit their loved ones in private. The homes systems for the receipt, storage and administration of medicines to residents are satisfactory so that residents are receiving their medication correctly. Staff receive training in the safe handling and administration of medicines. The temperature of the internal room used for storage of medicines was very warm and close to 25°C – the maximum recommended temperature for the safe storage of most medicines. The extractor fan was not working and should be repaired so that there is better ventilation and cooling to this room. Mon Choisy DS0000013112.V299878.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The residents enjoy the meals and mealtimes. There is a limited range of personalised activities suitable for residents with dementia. EVIDENCE: Sixteen out of 17 residents’ comment cards stated that they ‘always’ like the meals at the home. Ten residents are ‘always’ satisfied with activities, three said ‘usually’ and one ‘sometimes’. The relatives’/visitors’ comment cards showed that they are always made welcome when they visit this home. Most residents prefer to use the sitting room overlooking the front drive where they can watch the ‘comings and goings’ of the main Kennington Road. There are comfortable armchairs for residents in a larger dining-cum-sitting room where several residents enjoy reading or sitting quietly. A new large screen TV has been purchased for the large sun lounge overlooking the rear garden. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 13 One resident said that they join in card games or some board games with other residents, but otherwise stays in their room and watches TV because there are not many people to talk to (because they are confused). More mobile residents enjoy walking out in the garden at the rear of the house. There are limited personalised activities and little evidence of individualised care plans relating to the social and pre-admission recreational preferences and needs of residents. There is a high proportion of residents that have short-term memory problems and the inspector suggests that these residents need to be involved in individual and shared activities in a more ‘ad hoc’ way, matched to their past interests and day-to-day abilities. Developing ‘life stories’ with residents and their families would help staff to be aware of the types of recreational activities that could be adapted to residents’ current abilities. Mon Choisy DS0000013112.V299878.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents feel safe and listened to and are helped to live as independently as possible. EVIDENCE: The home’s complaints procedure is included in the service users’ guide. In practice, residents rely on relatives to know what is written in the guide, because they have received and signed the contract and chosen the home on behalf of the resident. However, 14 of the 17 residents who completed comment cards said that they ‘always’ knew how to make a complaint, whilst two felt they ‘usually’ could and one ‘never’. Fourteen residents ‘always’ knew who to speak to if they were not happy, two said ‘usually’ and one ‘sometimes’. There is evidence of regular training sessions in adult protection issues for staff. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The home’s own complaints record had no entries. Residents spoken with all felt confident that they are able to speak to the staff and manager if they are not happy about anything to do with their care. Many of the current residents are mentally frail and not able to exercise their right to vote at election time. The postal voting system is used for residents, or arrangements are made to get those who wish to go, to the local polling station. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The standard of cleanliness and décor are good but a number of pieces of furniture and fittings need replacing. The management is working to improve the standard of maintenance and the environment. EVIDENCE: The comment cards of 15 of 17 residents said that the home is ‘always’ fresh and clean and two that this is ‘usually’ the case. One relatives’/visitors’ comment card stated there had been a delay in getting repairs and maintenance done to a resident’s room. The home was clean and homely, but the front sitting room smelled of urine. The deputy manager said the carpet was going to be shampooed later that day. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 16 Almost all bedrooms still have linoleum type flooring as noted at previous inspections and many have metal-framed beds, that give a somewhat institutional feel. The provider stated that if a service user preferred other types of bedroom furniture and flooring, this would be provided by the home. Some rooms had had rugs added at the request of families. The inspector recommends that residents’ rooms should be carpeted from the outset, and washable flooring only used if the resident requests this or whose care needs specifically indicate that hard flooring is more appropriate, for example if someone needs to use a wheelchair frequently, or has severe incontinence. Any alteration to the type of flooring would need to be discussed with the resident and/or their representative. Some items of bedroom furniture were shabby or damaged, for example a bedroom chair with a protruding wooden joint peg, and one with a torn seat cushion. These have the potential to cause injury to residents and detract from otherwise largely well decorated and attractive rooms and should be repaired or replaced. The first floor bathroom fixed bath seat underside showed signs of accumulated scale and deposits - staff should check and clean shared bathroom equipment thoroughly, to reduce the risk of cross-infection between residents. The hot water flow to first floor washbasins in rooms was sluggish – the inspector tested this late in the morning of the inspection and the deputy manager suggested that this was because water had been run off for residents’ baths earlier. Mr Audit, the proprietor, was supervising a newly appointed maintenance worker and was busy around the home doing maintenance tasks on the day of the inspection. Some broken and missing window handles were noted in bedrooms. One first floor sash window that overlooks the driveway at the side of the house was fully open and needs window restrictors fitted. The manager said that the windows had all had screws fitted to the frames to limit the openings and this window must have lost its limiter. The windows should be checked and handles and limiters be in place to prevent the risk of accidents to residents. The outbuildings at the rear of the home are accessed via a sloping path and are used for dry goods and supplies storage, several freezers, cleaners’ room and laundry. One room had paper sacks of potatoes on the floor - the potatoes are kept there to keep them cool, but should be on a rack off the floor to prevent rodent or insect damage. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 17 The laundry room floor has a thin concrete screed exposing a plastic drainage pipe. The exposed pipe is redundant – all the water drainage is at the rear of the machines and appropriately deep Mr Audit said. The laundry floor and walls should be impermeable and readily cleanable. There were no gloves for care workers seen in the laundry. The manager said that staff clean off heavily soiled items before putting them into the sluice cycle of the washing machine. There is no ‘red bag’ system to protect staff from contact with heavily soiled/contaminated laundry. The inspector recommends that the advice of environmental health and infection control officers be sought regarding the protective clothing/equipment needed for staff to minimise the risk of contamination and infection from soiled laundry and when cleaning and disinfecting commode inserts. One washing machine had been out of order for some time but Mr Audit was organising the repair. Mon Choisy DS0000013112.V299878.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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The day staffing levels are adequate to safeguard the welfare of residents living at the home, but night staffing levels should be improved to result in better outcomes for residents. The home’s procedure for recruiting new staff is systematic but the formal processes for checking staff eligibility to work should be improved so that the home can demonstrate a robust process is in place for the protection of the residents. The management team shows a commitment to the training and development of all staff. EVIDENCE: Analysis of the comment cards received showed that five of the six relatives/visitors considered that there were sufficient numbers of staff on duty. Of the three GP comment cards, all felt that the home ‘communicates clearly and works in partnership’; one did not consider that there is ‘always a senior member of staff to confer with’. Residents’ comment cards showed that 15 considered that there are ‘always’ staff available when needed, two said ‘usually’ and one ‘sometimes’. Many of the staff work in both Kirlena House and Mon Choisy. The duty rota shows that most staff work in excess of 40 hours per week at Kirlena House, covering both night and day shifts, and have split days off. Senior care staff are rostered to be ‘sleep in and on call’ overnight, when they have already worked a day shift. These working patterns may cause staff to become Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 19 overtired and more prone to accidents that could adversely affect residents and themselves. It is recommended that staff work-rotas are revised to ensure that staff do not work mixed night and day shifts in a week and have adequate rest periods in between. The home’s own description of the dependency and care needs of the current residents indicates to the inspector that the staffing numbers overnight – one waking member of staff and one ‘on-call’ in the house – may be insufficient and should be increased to have both staff on ‘waking’ duty. A resident told the inspector that they did not feel that there were sufficient staff on duty at night and that they found difficulty in understanding most staff because of their poor spoken English. However, the resident stressed that the staff are all very kind and caring. The inspector recommends that the home’s manager and owner review the night staffing levels and take appropriate action according to the outcome. A sample of four staff members’ recruitment files was examined. There were some missing details – for example, one staff member’s Criminal Records Bureau (CRB) check had not been received, but Mr and Mrs Audit explained that adequate safeguarding procedures were in place so that residents were not at risk, because the person was working under supervision. Other satisfactory references and checks were in place. Another staff member should have a CRB check undertaken through the home’s own ‘umbrella body’ as CRBs are not transferable between employers. Evidence that a person’s work permit had been amended was not available. This was discussed with Mr and Mrs Audit who confirmed that the relevant checks and assurances had been applied for. They were advised to update the files to demonstrate that their employment processes are robust and protect residents. The home’s induction, training and supervision records were well-organised and showed evidence of an established system for ensuring that staff are adequately trained and competent to look after the residents. Training provided in the home over the past 12 months has included ongoing food hygiene instruction, adult protection, medications, care of residents with dementia and/or ‘challenging’ behaviour, induction and foundation training for new staff, fire safety, first aid, nutrition, staff supervision and appraisals. 53 of care staff have attained NVQ Level 2 or above. Ten have current first aid certificates. Mon Choisy DS0000013112.V299878.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): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The management arrangements for the home are sound and there is a system of monitoring the standards of practice that involve residents and their families. EVIDENCE: Mr and Mrs Audit and their deputy manager have more than 25 years’ experience in running care homes for older people. Both Mr and Mrs Audit are currently undertaking the Registered Managers Award in Care to meet the recommendations of the CSCI for necessary qualifications for registered managers. In addition to the deputy home manager and care leader, the home’s registered manager and co-owner, Mrs Audit, is available to provide advice and support to staff in both care homes as needed. Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 21 The home produces its own quality assurance questionnaires for relatives. These had been sent out in February 2005 and another set of surveys has just been distributed. A brief review of the home’s QA responses showed them all to be ‘very satisfied’ or ‘quite satisfied’ with the home and services. The inspector suggests that the quality assurance system should be further developed to include doctors and other health and social care professionals who visit their clients in the home. The home has satisfactory procedures to safeguard residents’ personal allowances and record small transactions made on behalf of residents– for example, hairdressing and chiropody charges - if the resident is no longer able to do so independently, and does not have a family member or representative to deal with this for them. Staff have to manoeuvre laundry and goods up the steep access covered pathway to the outbuildings at the rear of the home. Risk assessments for staff should be in place and consideration given to improving the access and means of transporting goods and laundry, to reduce the risk of injury to staff. Mr Audit said that the laundry and storage areas were being reconfigured. Mon Choisy DS0000013112.V299878.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Further improve residents’ care plans by adding more information about whether the planned care interventions have successfully met the resident’s needs (evaluation). Improve the assessment and care planning for residents’ social and psychological care needs. Improve the ventilation of the medicine storage room to keep the temperature below 25°C. Improve the scope and variety of activities suitable for residents with dementia, based on individual’s ‘life story’ information. The home should review all bedrooms where linoleum-type flooring is not agreed as a part of the care plan and carpet those rooms. Where beds are to be replaced, consideration should be given to the use of domestic style beds. 2. 3. 4. OP9 OP12 OP24 Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 24 Repair or replace all damaged items of furniture. 5. OP26 Ensure thorough cleaning of bath hoists and bathing equipment used in shared bath/shower rooms. Ensure that the hot water supply to residents’ rooms is constant throughout the day. Consult with infection control and environmental health officers about the measures needed for staff protection. A red bag system should be in use in the laundry, so that staff do not have to handle heavily soiled items. The laundry floors and walls should be impervious to allow thorough cleaning. Ensure that dry goods and vegetables are stored off the floor, to reduce the risk of rodent or insect damage. 6. 7. OP27 OP29 Review night staffing levels and take appropriate action according to the outcome. Ensure that the reasons for any missing or delayed checks and references for staff employed in the home are documented in their files, together with any interim safeguarding strategies that are in place for the protection of residents. Extend the scope of the home’s own quality assurance surveys to include the views of health and social care professionals. Replace any broken or missing window handles and ensure that all windows above ground floor, accessible to residents, have effective opening limiters fitted. Risk assessments for staff transferring goods and laundry between the home and utility areas in the outbuilding should be undertaken and safe moving and handling policies and procedures should be in place for the protection of staff. 8. OP33 9. OP38 Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mon Choisy DS0000013112.V299878.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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