Inspection on 10/10/07 for Mondial

This inspection was carried out on 10th October 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mondial 23/09/08

Mondial 07/11/06

Mondial 20/12/05

Mondial 18/05/05

Mondial 19/10/04

Mondial 08/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Mondial 3 Old Road Clacton On Sea Essex CO15 1HX Lead Inspector Marion Angold Key Unannounced Inspection 10th October 2007 11:45 Mondial DS0000017889.V352779.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 Mondial DS0000017889.V352779.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. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mondial Address 3 Old Road Clacton On Sea Essex CO15 1HX 01255 420995 F/P 01255 420995 Mondial3oldroad@aol.com 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) Mr Robert Clarkson Mr Robert Clarkson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Mondial provides a service for three people with moderate learning disabilities, situated in the heart of Clacton, near to shops and other amenities. Mondial is a detached bungalow with three single bedrooms, all with en-suite toilets. Two of the bedrooms are on the ground floor, along with a bathroom, kitchen, lounge and conservatory. The upstairs accommodation includes a laundry and a room for the member of staff sleeping in at night. A large garden is situated to the back of the house and the small front garden, has off road parking. The current weekly charge for a room is £520.87. Residents pay for their own transport and newspapers. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector went to the home without telling anyone she was going to visit on the morning of 10 October 2007 at 11:45. During this visit the inspector • • • • • spoke with 3 people living at the home spoke with 2 people working at the home watched how people living and working at the home got along together looked around some of the home looked at some records. In writing this report, the inspector also used information received about the home since the last inspection, including the Annual Quality Assurance Assessment (AQAA), completed for the Commission by the owner and manager, Mr Clarkson. What did the inspector find? 24 Standards were inspected. • 12 Standards were met. These are things the home does well for the people living there. • 11 Standards were nearly met. These are things that need a little improvement. • 1 Standard was not met. This is something that needs much improvement. What the service does well: People living at Mondial could expect • • • • • family-style accommodation and living; continuity of care and support from a small team of staff and manager, who knew them well; clean, comfortable and well-maintained surroundings, suitable for their needs; to enjoy their meals to be listened to and treated with respect. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? • • • • The service user guide had been amended to show that people living at the home would be actively supported to follow their own beliefs. Individual accounts had been opened for each person so that their money did not have to go through the home’s business account. New arrangements for storing the medication administered to people living at the home were satisfactory. Having an additional member of staff (making 4 in all, including the manager) allowed for greater flexibility in arranging shifts and for supporting people outside the home. Staff had undertaken more training for their work of supporting people. • What they could do better: • Each person must have a copy of a care plan that has been agreed with them and tells them what they are aiming to achieve and all the ways that they can expect to be supported and protected whilst living at Mondial. This will enable them to work towards their personal goals. Staff need up to date information about what to do if they heard about, or suspected, that someone was being abused. A record must be kept in the home to show which staff are on duty each day. The person in charge must carry out all the required checks before employing anyone to work at the home. This is to protect the people living there from anyone who would not be suitable to work with them. New staff must have the kind of training that prepares them fully for their work of supporting people. • • • • 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. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 7 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 Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People thinking about coming to live at the home can expect an assessment of their needs to determine whether Mondial can offer them appropriate care and support. EVIDENCE: The Statement of Purpose and Service User Guide had been updated since the inspection and each person had a copy of these, together with the complaints procedure. New contracts had been agreed with each person in June 2007 although none had a copy of their individual care plan, which should be part of the contract. There had been no changes to the resident group. Existing residents had been admitted on the basis of individual assessments of need. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Mondial could not be certain that all their needs and aspirations would be met through their care plans. EVIDENCE: Each person living at Mondial had a care plan, covering key aspects of their lives. However, the care plans did not fully reflect the support individuals were receiving whilst living at Mondial. One person’s care plan covered only personal hygiene, behaviour, support with finances, social life and activity. It did not touch on a medical condition, which significantly affected their life or specify interventions to guide care staff in the recognition and management of the condition. Another person’s healthcare needs were also not planned for. Most aspects of care were covered in the care plans only briefly. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 10 Another person’s care plan was similarly very brief, as were entries in columns headed ‘expected outcome’ and ‘actual outcome’. There was little evidence of people’s whole needs being reassessed since their admission to Mondial House. One of the care plans had been reviewed on a six monthly basis but the issues it covered had not changed since 1999. In both cases monthly evaluations had not taken place since June 2007. This meant that those living at Mondial could not be certain that all their needs and aspirations were being met through their personal plans. The third care plan inspected bore the most relevance to current issues for that person, having been updated in respect of changes in the law, affecting one of their identified needs. The last recorded evaluation was 1/7/07. The support individuals were receiving to take and manage the risks in their lives was not fully documented. Individual risk assessments were kept on file with health and safety information rather than with respective care plans, which did not promote confidentiality. One of these risk assessments related to the medical condition referred to above and was not covered in the person’s care plan. Others related to bathing, medication and being out in the community. These individual risk assessments had not been reviewed since 2003, which meant that they might not be offering adequate protection or support to the people concerned. It was evident from observation and discussion that people living at the home were involved in planning for their care in an informal way. They did not have copies of their care plans or know what was written in them. Care plans were kept upstairs in the staff bedroom. There was no evidence in the records of their active participation in the care plan and one person, aware that we were inspecting their individual plan, asked several times what it said. Information sent to the Commission by the manager/owner of Mondial (in the AQAA) identified their intention to promote service user involvement in the care planning process, qualifying this with the statement ‘our service users show little interest currently in the literary side of care planning, only the end result of how it affects them’. Since the last inspection, separate accounts had been opened for each person so that their weekly benefit no longer went through an account used for the business of the home. Staff explained that personal allowances were cashed each week and held by home for safekeeping and any money remaining at the end of the week was put aside until paid into respective savings accounts. The inspector stressed that at no time should this money be pooled. Staff explained that receipts were kept for clothes and large items but not for money, paid to service users for day-to-day expenditures they made of their own accord. The balance of personal allowance in the holding pouch for one person matched the record of transactions, which had been signed by the person concerned. There was a separate column showing the total money held by the home, which was made up of the unspent personal allowance, Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 11 accrued over a number weeks. The service user concerned knew how much money that was held by the home and in their savings account. The fact that money was building up, despite people going out independently on a daily basis, suggested that it might be appropriate to review their daily budgets and the opportunities they could be supported to take up in the community. Decisions made in this respect should be clearly documented in individual care plans. During the inspection, one person returned to the home to collect £1.00 for chips. This was taken from their personal allowance and they signed the transaction record. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst the routines and lifestyles suited those people living at Mondial, there remains scope for broadening individual experience and increasing opportunities for choice and participation. EVIDENCE: Residents’ lives outside the home had changed little since the last inspection. They all went out and about independently in Clacton and took themselves to the particular occupational, training or drop-in centres they regularly attended; one went to the library and two attended different churches. One resident used public transport independently to a known destination and this had increased to a weekly rather than a monthly excursion. Bedrooms reflected the personalities and interests of their occupants and they could watch television or listen to music in their own space if they chose to do so. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 13 Since the last inspection the home had taken on an additional member of staff, part time, partly with a view to supporting people in activities outside the home. Two people living at the home spoke about an outing to London that was planned. Support had continued for people living at the home to maintain links with their relatives and friends. Two people volunteered information about contacts with family. One person produced an album containing photographs of a milestone birthday celebration with church friends, and the watch, which had been presented to them. (They said that birthdays were not marked in any special way by the home). Information sent to the Commission in the AQAA showed that people had use of a telephone whenever they chose. Staff spoke about this during the inspection. The portable handset meant that people could speak in the privacy of their rooms. Following the last inspection, a review of one person’s care by Social Services raised concerns about the people living at the home having limited choice in relation to their clothing and shoes and not having opportunity to make drinks or participate in meal preparation. They had also found that people had not had a holiday for 8 years and thought they should not use the lounge after 21:00 hours. This reflected similar findings at the last inspection. This inspection showed more positive outcomes in these areas. There was discussion between one member of staff and a person living at the home about helping them to choose new clothing. One person mentioned watching a late film. A day trip to London had been planned. The AQAA indicated that people could help, plan and prepare meals if they chose to do so but that change in this area was difficult to achieve because individuals were not motivated to be involved. Records kept by the home for 10 days as a monitoring exercise showed that the person concerned had declined to help with meal preparation on a number of occasions. From evidence on the day of inspection, however, it appeared that still more could be done through care planning to actively promote individual involvement in activities that would develop independent living skills. People living at the home said they kept their rooms tidy but that staff took full responsibility for laundry, meals and drinks. Two people were given ham and cheese sandwiches and a banana for lunch and said they enjoyed this. The third person living at the home collected £1.00 personal allowance to buy chips in preference to having lunch at Mondial. This was a weekly arrangement and showed that they had been given choice. One service user told the inspector that at Mondial they all had the same meals prepared for them and they were good. The member of staff on duty said they did on occasions invite someone to help make their own sandwich and that, for the main meal, they would present 2 or 3 items and let people choose. People living at the home were Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 14 called to the kitchen at the end of the inspection to choose from several items in the freezer that the member of staff would heat for the evening meal. Mondial DS0000017889.V352779.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People experiencing this service could expect to receive personal support in a manner that promoted their independence and dignity but would be better protected if their healthcare needs were covered by their care plan. EVIDENCE: It was evident from a situation arising during the inspection that people could choose when to have a bath and that the support they received in this area promoted their independence and dignity. Records of healthcare appointments, and discussions with staff, showed that people living at the home were supported to look after their health, although this was not fully documented in their care plans, as the section on Individual Needs and Choices makes clear. Care plans for two people living at the home did not specify what support staff were to give in respect of medical conditions that significantly affected their individual lives. In one case, the related risk assessment was not on their individual file. The other did not have a written Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 16 risk assessment. In talking about the support given to one of these individuals, the member of staff on duty said they knew how do deal with their medical condition, although instructions were not written down. Incidents of the condition were entered in the daily records kept by the home. However this did not enable staff to easily gain an overview of the frequency, duration and possible triggers of the episodes. Following advice at the last inspection, residents’ medication and medication administration records had been moved to a metal filing cabinet in the staff bedroom, where they were stored in individual hanging files. Staff had training from the pharmacy they use in June 2004 and colleagues had trained the new member of staff, who was responsible for medication on their shift. Although the procedures were simple for the size and needs of the present service users, all staff should have accredited training or refresher courses to ensure their practice is safe and up to date. Mondial DS0000017889.V352779.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home could expect to be listened to and well treated but staff’s lack of knowledge of new safeguarding adults methodology might not fully protect individuals in the event of an allegation or suspicion of abuse. EVIDENCE: No complaints had been received/recorded by the home. Concerns about people living at the home having limited choice and opportunities were raised by Social Services, following the last inspection, and have been covered under the section headed, Lifestyle. Examples of the home developing service user choice and participation were given. These areas need to be considered in detail for each person and incorporated into their plan of care. People were positive about how staff treated them and their experience of living at Mondial. It was evident from observation that they found the two members of staff, present during the inspection, approachable. The complaints procedure had been reviewed on 29/06/07 and a copy was included in the information people had about their home. The role of the Commission for Social Care Inspection, in relation to complaints, had not been clearly stated in the home’s procedures. It should be noted that the Commission is not a complaints agency and does not have statutory powers to investigate complaints. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 18 The home’s Protection of Vulnerable Adults policy was last reviewed on 1/7/06, which predated new safeguarding adults protocols for Essex. The two staff present during the inspection were not aware of the new guidance, which applies to all people involved in caring. This inspection identified that people could be placed at risk through shortfalls in recruitment procedures (see section on staffing). Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People, living at Mondial benefited from clean and well-maintained and presented surroundings, suitable for their needs. EVIDENCE: Mondial continued to present just like a family home and be well maintained, comfortably furnished, fresh, clean and tidy. Communal areas had been redecorated. The atmosphere in the conservatory was fresher as it was no longer being used for smoking. The garden was also attractively and neatly maintained. A new drive, paving and lawns had been laid in the front since the last inspection. The home felt cool on entry. Information given to the Commission (in the AQAA) stated that staff had been reminded to check the ambient temperature Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 20 of the home using a wall thermometer. The thermometer was in place and staff on duty confirmed this to be the practice. The home became warmer after they had turned on the heating. As the heating was not thermostatically controlled, people living at the home depended on staff to ensure that rooms were sufficiently warm to meet their needs. The bedroom inspected was comfortable, suitably furnished and personalised. Hot water, sampled at the hand basin in the en suite facility, was at least 56.7 degrees. A similar situation was noted at the last inspection. Whilst acknowledging that water temperatures were not thermostatically controlled, the person on duty indicated that this did not pose a risk to people currently living at the home. This should be documented. Risk assessments should also be in carried out in respect of radiators with hot surface temperatures. The home was clean and fresh in all areas inspected. Separate laundry facilities suited the needs of residents. Staff had completed infection control training. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home were not fully protected by the home’s recruitment and staff development practice. EVIDENCE: Staff could not locate a duty roster. They said the manager had possibly taken away the rosters to calculate wages. An additional person had been employed since the last inspection, making 4 on the team, including the manager. One person living at the home said that having an extra person was good because it meant staff did not get too tired. Staff said that having an extra person to call on would enable them to support people with outings. The first outing, to London, had been planned. The number of staff covering each shift remained at 1. In his absence, the manager gave permission for staff to open the filing cabinet containing staff records. These were held in the staff bedroom. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 22 Not all the records and documentation required by regulation had been obtained for the new member of staff. There was an incomplete employment history, only the last employment being given, and no dates. One record showed that a verbal reference had been obtained on 8/8/07 but there were no recorded details of this. A Criminal Records Bureau disclosure was dated 6/9/07 but there was nothing to say whether this pre-dated the person’s employment, as there was no start date on the file. For all three staff the record of induction was a one-page tick list. In the case of the newest member of staff this had not been dated. The other two records showed that this induction had been completed on one day. Staff said the new person had shadowed members of the team for a fortnight and then been supported by existing staff on their initial shifts. People living at the home remembered that the person had worked in the home 7 years ago. Records held on individual staff files showed that they had attended 2 or 3 training courses each year. Since the last inspection, two people had attended sessions on infection control and basic awareness of diabetes and one had completed the National Vocational Qualification (NVQ) in Care, Level 3. Three out of 4 people working in the home, which included the manager, who covered shifts, had achieved NVQ Level 2. Annual appraisals had been completed for two staff. There were no supervision records for the newest member of staff and, records for the others, showed that supervision was not regular and more like an appraisal, being a brief resume of how the person was getting on rather than focussed on practice issues. Staff said that because of the small scale of the home and close working relationships of management and staff, issues tended to be covered informally on a day-to-day basis. Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The safety and quality of life of people living and at the home could be compromised by shortcomings in management systems and quality monitoring. EVIDENCE: A number of shortfalls highlighted at previous inspections were still outstanding or only partially addressed. Various breaches of regulation have been identified and remain the responsibility of the manager/provider. Surveys recently returned from 5 family members showed they were confident about all aspects of their relative’s care. They included some positive comments. Two of the questions in the home’s survey needed modification so Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 24 that relatives could answer them. For example, they would not know whether staff had received training, as they were asked, but might be able to express a view about the competence and skills of staff. Surveys completed by people living at the home were not dated. Not all the information supplied to the Commission in the manager/owner’s self-assessment of performance (AQAA) could be corroborated by the findings of the site visit. The manager/owner did not feel areas could be improved where significant shortfalls were identified by this inspection, such as in care and risk management, and staff recruitment and development. Following a recommendation in the last report, some of the home’s policies and procedures had been reviewed. This process needed to be continued. The home had introduced daily records of the temperature of the hot food served and freezer temperatures. They continued to maintain records of what each person living at the home had to eat. Keeping the home suitably warm, and the need for risk assessments in respect of hot water and radiators, has been addressed under the section on the environment. Records showed that safety checks in respects of gas appliances had been carried out. Portable electrical appliances and fire extinguishers were due for testing. Electrical circuits also needed checking because the last review, in June 2002, had exceeded 5 years. Ensuring these tests are carried out when due should be part of the home’s annual review of the quality of care and provision. Mondial DS0000017889.V352779.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 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 2 X Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 YA19 Regulation 15 Requirement Individual care plans must fully cover the health and welfare needs of residents. This requirement has exceeded the timescale of 31/01/07, agreed after the last inspection. A duty roster must be maintained and available for inspection of persons working at the care home, including a record of whether the roster was actually worked. This requirement has exceeded the timescale agreed following the last inspection. Staff records must include all the documents and information listed under Regulation 19, Schedule 2 and Regulation 17, Schedule 4 of the Care Homes Regulations 2001. This requirement has not met agreed timescales since June 2003. Timescale for action 01/12/07 2. YA33 YA41 17(2) Shed 4 10/11/07 3. YA34 YA23 17,18,19 01/12/07 Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA5 YA6 YA7 Good Practice Recommendations People living at the home should have a copy of their care plan and details of any part of this, which is to be provided outside the home. People living at the home should be as involved as they can be in their care plans. Care plans should be sufficiently detailed to reflect individual progress in identified areas. They should also document how decisions have been reached. Risk experienced by people living at the home should be re-assessed periodically and kept under regular review. Staff need to be familiar with revised safeguarding adults protocols to ensure that people in the home are fully protected in the event of a situation or suspicion of abuse. Risk assessments should be carried out in respect of the temperatures of rooms, hot water and radiator surfaces. New staff should be inducted using the Skills for Care Common Induction Standards, to prepare them fully for the work they are to perform. Staff should have regular supervision to help their professional development and ensure that their practice promotes the best interests people living at the home. Records should be signed and dated to give them value and context. 3. 4. 5. 6. 7. 8. YA9 YA23 YA25 YA24 YA42 YA35 YA36 YA40 YA41 YA34 YA39 Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Mondial DS0000017889.V352779.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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