Inspection on 24/07/07 for Mon Choisy

This inspection was carried out on 24th July 2007.

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 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 16/07/07

Mon Choisy 22/06/06

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Mon Choisy 128 Kennington Road Kennington Oxford OX1 5PE Lead Inspector Ruth Lough Unannounced Inspection 24th July 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mon Choisy DS0000013112.V367592.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.V367592.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.V367592.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. 16th July 2007 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 to 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.V367592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use the service experience adequate quality outcomes. This was a Key Inspection process generated by the Adequate, findings from an inspection visit to the home in July 2007. The inspection included using information supplied by the home in the Annual Quality Assurance Assessment, self-assessment document, and records reviewed during a one- day visit to the service. Surveys were sent to the home for the people who live in the home and staff to complete. At the time of this report six surveys had been returned to the commission, four from people who use the service and two from staff. We also took the opportunity to talk to the people living in the home, staff, and visitors. What the service does well: What has improved since the last inspection? The records for care planning have improved with the use of summaries for the monthly reviews to identify the key changes in the care that have taken place. This is helping staff to monitor the needs of the individual over a longer period and should assist with planning of care for the future. Some redecoration in communal areas has made it more pleasant and welcoming to live in. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Mon Choisy DS0000013112.V367592.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.V367592.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users needs are assessed thoroughly before they are offered a place in the home. EVIDENCE: The care records for two people living in the home were reviewed as to establish if their assessment of need is carried out thoroughly before they are offered a place. Both had been admitted to the home within the last four months through a social services referral process. From the information provided it was evident that for one service user suitable information had been obtained about their medical health, physical wellbeing, and social needs. The other person’s records showed that the information obtained from the social service assessment was incomplete and the homes process did identify further detail about some of the individual’s needs, but not Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 9 all. Since admission significant care needs have been identified by the home and they are working with the family and social care professionals to find an appropriate place for the individual to be cared for. Mon Choisy DS0000013112.V367592.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. That service users care is planned for, and meets their needs. EVIDENCE: The care planning records for four people living in the home were reviewed as to see what is in place and how staff are provided with information to be able to carry out support to meet the individuals needs. The records are organised in a fixed care planning system (Standex) and additional documents about the individual are kept in various other records. These include personal history, risk assessments, health appointments, and contractual agreements to stay in the home. The majority of the record reviewed showed that the main topics of the persons identified needs have the necessary information about how staff are to meet them. There were also additional monitoring tools for assessing their weight, mental state, dependency, and sleep patterns. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 11 The care planning records at the beginning provide a brief overview of the person’s key needs taken from the assessment process. However, one record that was seen could have included better detail of the person’s previous health needs/ treatment as these could effect how staff support’s the person. The care records seen did not indicate that there were further documents to review such as the risk assessments that are kept separately. There were some good records for monitoring the emotional and behaviour patterns for the one person as previously identified. The detail that staff are writing in the daily records show a picture of the mental wellbeing of the person concerned. The processes for the administration of medication in the home were reviewed. This was to see if staff have been provided with the necessary information to support the service users for this, and that safe practices are carried out. Information about individuals medication needs are recorded in their care plans during the assessment process. According to staff currently there are no service users living in the home who are able to self medicate. The home use the services of a local pharmacy who supplied the medication for each individual in NOMAD packs(Pre – dispensed cassettes) with an accompanying MAR(Medication Administration Record). From the records reviewed staff are generally recording appropriately any administration of medications carried out. However, the area where they note any changes to the planned administration have not been completed to give further detail. This could be because the document supplied by the pharmacy has missing information on the rear of the page. The manager confirmed that they would discuss this with the pharmacist as soon as possible. Photographs of the individual service users are provided with the MAR charts as to assist staff to administer medications to the right person. The home had implemented good records to ensure that the passage of medications in and out of the home is monitored well. They also have made sure that they have a secure room to keep all medications safe. Recent changes in the legislation for medication storage now require care homes to keep all medications in a metal cabinet that meets with specific safeguarding measures. The homes wooden cabinets now do not meet these regulations. The Manager was informed that they would be given a requirement to improve the storage facilities they currently have in place. This must be completed within the three months from the date of the inspection visit. The policy and procedures for medication administration were also reviewed to see if the staff have been provided with sufficient information. From the documents seen it was apparent that they could improve them and they were advised to refer to new guidance called, ‘ The Handling of Medicines in Social Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 12 Care’ from the Royal Pharmaceutical Society as to assist them carry this out. Training for the senior staff for medication is provided in the induction and training programme. The home has a small number of bedrooms that can be used as shared accommodation. Of those currently in use for this purpose, screening is provided between the beds and around the sink areas to provide some privacy. The manager did confirm that when able they prefer to provide the rooms as single occupancy unless the individuals choose otherwise. The policies, procedures, and some of the information made available to staff about caring for people at the end of their life were reviewed. Some information about personal choices is recorded in the care plans. Through discussion with staff it was evident that they do have a greater awareness of how some of the service users wished to be cared for at this point in their lives, than is recorded in the care plans. The manager has already recognised that staff knowledge for this particular need of the people who they care for should be developed and has already organised ‘Palliative Care’ as one of the topics training in the next few weeks. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is adequate. These judgements have been made using available evidence including a visit to this service. That service users are given the opportunity to exercise choice over their lives and be able to maintain some of their interests. Meals and menu planning meet their health needs and personal choices. EVIDENCE: The information and implementation of supporting individuals with meaningful activities was an area of weakness seen at the last inspection. Some of the information about individuals interests, choices and cultural needs is recorded in the care plans, but as yet the staff have not put into place a formal support plan to enable staff to achieve providing them. The manager did confirm that they were aware that this is an area that needs improving as to make the care and support provided more holistic. What they have done is supported some of the individuals to have private occupational therapy once a week. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 14 Through the surveys returned to the commission relatives and service users have expressed their desire for a greater variety of activities in the home and for the opportunity for trips out to be increased. One comment was, “I would like more group activities like the sing-a-longs, short trips outside the home would be nice sometimes.” During the visit to the home very little was seen of staff providing activities with service users. However, some of the service users were freely wandering around the home, others were observing what was going on around them and some were enjoying the company of their visitors. One service user was reading her daily paper. The hairdresser was present during the morning and the people having their hair cared for appeared to be enjoying the process and the company. A visiting Occupational Therapist was using the large sun-room at the rear of home with two people who were responding very well to musical therapy they were doing. Some of the activities that are provided include exercise to music as a group and others are more individually based such as games and cards. Staff have sought information about some of the individuals family and personal histories but this is still under development. We took the opportunity to speak to the senior cook who is in the home fours days a week and is responsible for the menu and meal planning in the home in conjunction with the manager. She was able provide information about the health and personal choices of each service user and how it is used in the development and implementation of the menus. She also provided information of what is available to people should they want something different to the planned meal and what alternatives are on offer. Staff are able to access snacks for service users for between meals if people should express they are hungry or have missed a main meal time. The cook provided information that they are able to support people with specialist dietary needs such as gluten free and for people who are diabetic. As identified during the last inspection process – the majority of the vegetables for meals are frozen but there is fresh fruit made available. There was no evidence that service users nutritional state or wellbeing, have been compromised by this. The cook also gave information that they do provide cakes and special celebratory tea parties for special events such as birthdays and other family celebrations. One person commented, “Food has been very satisfactory.” Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. That service users concerns or complaints are listened to and acted upon. The service has systems in place to protect the people living in the home from possible abuse or harm. EVIDENCE: The respondents in the survey did confirm that they new how to make a complaint and that they felt able to speak to a member of staff should they have concerns. The complaints procedure is provided to the service users in the Statement of Purpose and Service User Guide and has the necessary information included. The manager provided information that they have not received any complaints about the service over the last twelve months apart from one recently that was under investigation at the present time. During the day of the inspection visit the manager and senior staff were involved with a meeting in the home in regard to this and the outcome from this had not been provided to the commission at the time of completing this report. The commission has not been in receipt of any concerns about the home since the last inspection process. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 16 The home has been given a number of compliments since the last inspection process. Much of the comments were in reference to caring and supporting people well. One relative put that they felt reassured when they left the home that the person they cared for was being looked after well. The information in the home for safeguarding adults from possible harm and abuse was reviewed. The staff have access to the necessary information should it be required and the topic is included in the regular training programme. The staff who we spoke to in the home appear to have sufficient knowledge should concerns be raised and they are supported by the ‘whistleblowing’ policy that is in place. Staff did comment in the survey that they felt the manager was very approachable to discuss any issues. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. 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 homes environment in parts is not always maintained in the best interests of the people who live there. EVIDENCE: The home has not been built for its current use but has been adapted over a period of time. Originally a family residence it has had various changes made to improve the facilities, these have been mainly provided to the rear of the building. There is a small courtyard/ patio area to the rear that is accessible to the people who live in the home via the large communal room. Service users bedrooms are situated on the ground and first floor. The home has a second floor that is not used by the residents. There is a lift to the first floor for those not able to use the stairs. On the day of inspection it was observed that an empty bookcase had been put across the bottom of the Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 18 second flight of stairs. According to information given by the provider it was to prevent service users accessing the painting equipment stored on this level whilst a painter was in the building. However, they should look to professional guidance to ensure they provide suitable safety measures particularly those relevant to fire for this area. The bedrooms are of a variable size, some of which can be used as shared accommodation. None of the bedrooms have en suites but all have washbasins. There are bathrooms, separate showers, and toilets on each floor. However, one shower was awaiting repair and several toilets and a downstairs bathroom did not have paper towels or liquid soap for people to wash their hands. One of the toilets on the first floor appeared to be positioned poorly for access by people who are less mobile. This information was passed back to the manager during the inspection visit. The downstairs communal areas appear to be well cared for and it was evident that there was a programme of redecoration and refurbishment for them. Areas in the corridors on the first floor were being painted during the day of the inspection. A small number of the bedrooms that were seen had been redecorated and had flooring replaced since the last inspection. A greater number of the bedrooms reviewed showed tired and shabby furniture and in one bedroom, currently not in use according to staff, had incomplete floor covering and bare boards were exposed in parts. In other bedrooms some furniture although kept clean had handles missing, chips and damage to the surfaces and doors did not close properly. It was difficult to establish fully what was the service users own furniture from this brief assessment of the home. However, this topic was discussed with the proprietors during the day and they were strongly advised to carry out an audit of the rooms to establish fully the extent of the repair and replacement programme needed. Some of the vanity units surrounding the sinks in the bedrooms were very worn and reduce the staff’s ability to keep them clean and minimise to spread of infection in the home. It was identified in the last visit to that the furniture in some bedrooms was not in a very good condition. This appears to have not been rectified as swiftly as we would expect. Many of the rooms reviewed had commodes in situ and from information provided by staff a high number of the service users require to use these at night. The condition of some of the commodes is poor in places with the waterproof surfaces and handrails damaged in parts making it difficult to keep clean and reduce the spread of infection. We were informed by the manager that six new commodes had been purchased recently but as yet not been distributed around the home. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 19 The home does not have any aids to clean and sterilise the pans from the commodes at present. The pans are emptied in to the toilets on each floor and cleaned by hand by staff. The manager was advised to look at the Department of Health ‘Infection Control Guidance for Care Homes,’ to assist with reviewing the current practices and support staff to minimise risks. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The gaps in the employment practices could put service users at risk from people who may be unfit for the purpose they have been employed for. EVIDENCE: From information provided and reviewing the duty rotas there appears to be a sufficient number of staff during the day to meet the needs of the people who live there. At night according to the recorded rota and through discussion with staff there is one member of staff on duty with one sleeping in, to be called should they need assistance. Additionally, a senior member of staff are contactable each night for added support should they need it. Apparently this has been the practice for a considerable length of time. However, there was no evidence that the dependency needs of the people living it the home at night have been assessed to support the staffing levels during this period. The manager should also seek professional advice to ensure that this practice will be able to meet with fire safety as to a full evacuation of the home should it be required during the night. Staff were observed to be friendly and communicative with the people living in the home. For one service user, staff were particularly patient and empathic with them when they were trying to diffuse the persons anxiety and distress. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 21 The information provided by the manager about the qualifications in care that that the staff working in the home show that of the sixteen staff, five have obtained an NVQ 2 or above. Four staff are in the process of achieving an NVQ. The records for the recruitment and employment of two staff were reviewed to see if appropriate practices are in place and service users are protected and supported by skilled and experienced staff. Both care staff had been employed in the home since the last inspection visit in July 2007. Application forms, references, health declarations and the required Protection of Vulnerable Adults list and Criminal Records Bureau records had been obtained before they were employed in the home. The application forms seen did not require the person completing it to provide their full work history nor was there evidence of them providing a CV as supporting information. For one employee neither of the two references were from a previous employer, the other had provided the name of referee as a previous employer but it was unclear which employment it was in the history they had provided. Prospective staff attend a formal interview with notes recorded about the outcomes of the process. They are confirmed in post only after the induction process and a probationary period of three to six months has been completed successfully. Copies of any qualification or training certificates are taken, plus proof of address and a recent photograph are held in the employment records. They do not use a training needs analysis tool to identify what each member of staff needs to carry out their work. These needs are discussed in the supervision meetings that occur on a regular basis. From information provided in the staff survey returned to the commission and in discussion with staff during the day they thought they had been recruited appropriately. One staff confirmed that they had shadowed another senior carer for two weeks at the start of their employment. This mentoring, supervision, and probationary period for new staff is not recorded in great depth in the employment records that were seen. Each staff member is given a contract of employment and a job description outlining the key points of the role they have been employed for. The training information relating to the individual carers whose employment records were reviewed showed that the key topics of health and safety are included in the induction programme and additional training had been provided for Stoma care and dementia for one member of staff. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 22 We observed one member of staff not assisting a service user to mobilise across the room appropriately. They were putting themselves and the person concerned at risk by supporting them under the arm by using their forearm to take the persons weight and not guiding them in the approved way. The carer concerned was unable to remember the date of the last training she had undertaken for moving and handling. This was referred back to the manager during the visit. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. There are areas in the management of the home that are not run in the best interests of the people who live there. EVIDENCE: The Manager has been working in her role for since the home opened in 1985 she has attained an NVQ 4 Registered Managers Award. She is supported by a small team of care staff, one of whom takes the lead as Care Manager, and is responsible for much of the day to day running of the support for service users. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 24 Comments from staff in the survey and in the home did indicate that they felt the management of the home was supportive and provided them with the necessary training to do their jobs. From information provided there are some processes in place for formally consulting with service users about their opinion of how the service is provided. The last process was in October last year. As found during the last inspection visit in July 2007, they have not yet found a method of feeding back the information they have obtained from this exercise to the service users or others who have participated. However, they have used some of the information found in their business planning for the service. Small amounts of service users money is held and managed by staff in the home. This is usually used to pay for toiletries, newspapers, and hairdressing. The records for a small number of service users was reviewed and appeared to be in good order. A discussion with the care manager and manager highlighted that they are intending to review this process as to minimise any risks to service users money being retained by the home. Information in the Annual Quality Assurance Assessment, self-assessment document shows that they have a number of safe working practice checks in place. Including fire, water temperatures, and those for the lifting and handling equipment. During the process of the visit a concern rose about the storage of cleaning and garden fertilizer that should be kept under the regulations for Control of Substances Hazardous to Health (COSHH). They were found to be stored in the external food stores – even though this is highlighted in their own policy not to be carried out. Also during the visit the cleaner had left some cleaning solutions unattended in the corridor. The manager did confirm that the storage facilities for items that could be hazardous to health would be reviewed and that staff would be reminded of their responsibilities for safe practices. There was one other small area of concern as to the safety of service users and staff. The staff were seen to carry a tray of cups of hot tea from the kitchen to the lounge areas to be distributed to the service users. We were witness to one member of staff nearly colliding with a service user in the corridor as they left the kitchen and although no person was injured, this practice should be assessed and action taking to minimise any risks. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 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 2 X 3 X X 2 Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13.2 Requirement That a suitable cabinet is installed that meets the standard for the storage of controlled medications set in the Misuse of Drugs (Safe Custody) Regulations 1973. That the required information is obtained in regard to staffs full work history and professional references before they are employed in the home. That suitable safety measures are put in place to ensure that items that should be stored and used that come under the legislation for Control of Substances Hazardous to Health Regulations (COSHH) are not stored inappropriately with food items. Timescale for action 23/10/08 2. OP29 19 30/09/08 3. OP38 13.4 24/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 27 No. Refer to Standard Good Practice Recommendations Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mon Choisy DS0000013112.V367592.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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