Inspection on 23/09/08 for Mondial

This inspection was carried out on 23rd September 2008.

CSCI found this care home to be providing an Adequate service.

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

Mondial 10/10/07

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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Mondial 3 Old Road Clacton On Sea Essex CO15 1HX The quality rating for this care home is: 1 star adequate A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ray Finney Date: 2 3 0 9 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: Mondial 3 Old Road Clacton On Sea Essex CO15 1HX 01255420995 F/P01255420995 Mondial3oldroad@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Robert Clarkson Name of registered manager (if applicable) Mr Robert Clarkson Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 3 0 care home 3 learning disability Additional conditions: Date of last inspection 1 0 1 0 2 0 0 7 A bit about the care home Mondial provides a service for three people with learning disabilities, situated in Clacton on Sea, close to a large supermarket and a few minutes walk from the town centre shops and amenities. The seafront promenade is also within walking distance of the home. Mondial is a detached Care Homes for Adults (18-65 years) Page 4 of 32 bungalow with three single bedrooms, all with en-suite toilets. Communal areas include a bathroom, kitchen, lounge and conservatory. There is a laundry room upstairs and a room for staff. A large garden is situated to the back of the house and the small front garden has off road parking. Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 32 How we did our inspection: This is what the inspector did when they were at the care home A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as care plans and personnel files. An Annual Quality Assurance Assessment with information about the home was completed by the manager and sent to us at the Commission. Throughout the report this document will be referred to as the AQAA. A visit to the home took place on 23rd September 2008 and included a tour of the premises, discussions with people living in the home and members of staff. A completed survey was received from a relative. Observations of how members of staff interact and communicate with people living in the home have also been taken into account. On the day of the inspection the atmosphere in the home was relaxed. We were given every assistance from the staff on duty. Care Homes for Adults (18-65 years) Page 7 of 32 What the care home does well Mondial provides a comfortable family type environment for the people who live there and their bedrooms reflect individual tastes. A relative who expressed an opinion said, On my visits the standards of cleanliness are very good. Staff treat people living in the home with dignity and respect. A relative stated that what the home does well is the care shown to each individual, The needs of the individual seem a high priority with the staff. People living in the home are encouraged to maintain their independence, particularly around getting out and about in the community, meeting friends and socialising. People living in the home benefit from being cared for by a small staff team who know them well and who are committed to providing good quality care. Care Homes for Adults (18-65 years) Page 8 of 32 What has got better from the last inspection There have been some improvements in record keeping, including reviewing and revising care plans. Some of the homes policies and procedures have been revised and updated, including the complaints procedure and the policies around safeguarding, bullying and harassment. Care Homes for Adults (18-65 years) Page 9 of 32 What the care home could do better The storage of medication could be improved to ensure that peoples prescribed medication is securely and appropriately stored. The Quality Assurance process needs to be developed so that information obtained from seeking the views of people using the service, relatives, staff and other health and social care professionals is collated into a report that forms the basis of a development plan for the home. Record keeping could be developed further, particularly around risk assessments and care plans. The process for assessing risks should be developed so that there are risk assessments in place that cover all areas that might present a risk to people using the service or to members of staff. Improvements could be made around staff training so that their skills are updated and they can support the health, safety and welfare of people living in the home. People living in Mondial could be more involved in the day to day running of the home, such as having more involvement in preparing meals or setting the table. Care Homes for Adults (18-65 years) Page 10 of 32 If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Ray Finney CPC1 Capital Park Fulbourn Cambridge CB21 5XE 02079792000 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Care Homes for Adults (18-65 years) Page 11 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 12 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Through the admission process, people choosing to live at Mondial can be confident their needs will be assessed. Evidence: The manager states in the AQAA, The service user guide and statement of purpose have been reviewed and Service users have their own copy of the service users guide, statement of purpose and contract. Records examined confirm that copies of the updated service user guide and statement of purpose are in peoples individual files. There have been no new admissions to Mondial since the last inspection and there are currently no vacancies. However, there is a process in place for carrying out preadmission assessments. The manager states in the AQAA, Before accepting a place here service users are encouraged to spend some time with us to get to know everyone and to be sure they feel happy and comfortable. We have had the same service users for almost 10 years now. In the event of another service user joining us we would follow the policies and procedures and could then assess the need for any changes and Service users individual needs are assessed and reviewed regularly to Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: ensure that Mondial continues to provide a service that is appropriate to each individual service user. Care Homes for Adults (18-65 years) Page 14 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in Mondial receive care that meets their assessed and identified needs. Evidence: On the day of the inspection the care plans of all three people living in the home were examined. The care plans identify the persons need, the action required and the expected outcome. Individual files contain Personal Profiles that give good general background information about the persons life history. The small staff team at Mondial is well established and it is evident from speaking to both members of staff that they know peoples needs and wishes well. However, the level of knowledge that they were able to demonstrate was not reflected in the information in the care plans. The information in care plans is quite general and could contain greater detail to ensure that peoples individual needs are fully identified and all staff are meeting those needs in a consistent manner. Through discussions with a senior member of staff, they were able to demonstrate a commitment to developing the care plans and recognise that the care plans would be improved if they contained greater detail. Observations on the day of the inspection confirm that people are Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: receiving a good standard of care and further development of the care plans will provide better evidence of this. A relative who completed a survey stated, The needs of the individual seem a high priority with the staff and what the home does well is,The care shown to each individual. Throughout the course of the inspection we observed that people living in Mondial were making their needs and wishes known to staff. It was evident from discussions with all three of the people living in the home that they are confident in making choices and decisions about what they want to do. We also oberved good interactions between people living in the home and members of staff. The manager states in the AQAA, Service users are involved in decision making at all levels and their own goals are never overlooked. Risk assessments are in place but are stored in the Health and Safety file. Although this is appropriate for records such as the Legionella Risk Assessment, it is not appropriate for personal risk assessments relating to the people living in the home. Peoples individual risk assessments should be stored in their own files. As with care plans, risk assessments could be further improved if there was greater detail on the actions to be taken to reduce the identified risks. Care Homes for Adults (18-65 years) Page 16 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in Mondial can expect to enjoy a lifestyle that meets their wishes and interests. Evidence: Through discussions with the people living in the home, they explained about their interests and what they like to do. One person said they like reading books about racing and going out to the local bookmakers daily. They also said they like to watch programmes like Panorama on television. The manager stated in the AQAA, We support and encourage service users to be involved in various leisure and community activities and access local groups that they wish to be a part of. All three people living in Mondial go out independently to access the local community. One person likes to go the the local library and visits Colchester independently on a weekly basis. Two people said they enjoy going to the the local drop in centre to socialise with friends. One person attends two local churches Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: regularly at weekends and said they enjoy going to church events. There is evidence in peoples personal files that relatives are actively involved in their lives. All three people living in the home told us about the contact they maintain with their families, including visits, holidays and telephone calls. A relative who completed a survey stated the home, Usually helps their relative keep in touch and any information requested has been met quickly. The manager stated in the AQAA, families and friends are always welcome at Mondial and service users are given privacy during visits. Individual records contain evidence of peoples end of life wishes and funeral plans. One person said they would like flowers but not wreaths so that they can be taken home by friends and relatives to be enjoyed instead of wasted. Although people living in the home are involved in the local community, they are less involved in the running of the home and would benefit from being encouraged to participate in day to day activities such as helping to prepare meals. Following discussions with a member of staff during the inspection, she discussed this with the people in the home and one person told us before we left that they had prepared cheese and biscuits for after dinner. The member of staff said that they will try to encourage people to have more involvement in the home. The manager stated in the AQAA, Service users are offered a choice of nutritious and appealing meals. All those spoken with said they enjoy the food in Mondial. Staff spoken with said that people are able to express their likes and dislikes. Care Homes for Adults (18-65 years) Page 18 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can expect their personal and healthcare needs to be identified and met, although they cannot be confident that they will be safeguarded by the way their medication is stored. Evidence: The people living in Mondial do not require a high level of support with personal care and are mainly self caring with some prompting from staff. Through discussion, staff spoken with were able to demonstrate that they know people well and understand what support is needed and what way the individual prefers to have that support carried out. A relative who completed a survey stated that the home, Always meets the needs of [my relative]. Care plans could contain greater detail to ensure there are clear guidelines for staff so that any personal care required is provided consistently. The manager stated in the AQAA, Service users receive support in the way that is preferable to them individually and Service users are treated with dignity and respect and are therefore comfortable with receiving personal care. Throughout the day of the inspection staff were observed to treat people with respect. Care Homes for Adults (18-65 years) Page 19 of 32 Evidence: Care plans examined contained some information about peoples healthcare needs including diabetes. There is evidence in the records that people are supported with visits to the GP and with their chiropody needs. However, care plans examined did not contain sufficient detail about individual healthcare needs or what measures are in place to meet those needs. The manager stated in the AQAA, Medication is stored, recorded and administered properly and in accordance with service users needs and the homes policies. No one living in the home currently manages their own medication. There is a monitored dose system in place for managing medication within the home. Medication Administration Record (MAR) sheets examined were completed appropriately. The storage of medication was examined and found to be inappropriate. The current storage facility is a lockable filing cabinet. Guidelines for the handling of medicines in social care, available from the Royal Pharmaceutical Society of Great Britain, state that when medicines are stored centrally the cupboards must be big enough, well constructed and have a good quality lock The current storage facility does not comply with these guidelines. Legislation states that care homes must store controlled drugs in a controlled drugs cupboard, including care homes registered for personal care. A controlled drugs cupboard is a metal cupboard of specified gauge with a specified double locking mechanism that is securely fixed with either rawl or rag bolts to a solid wall or a wall that has a steel plate mounted behind it. Mondial does not have a controlled drugs cupboard. Although no controlled drugs are currently in use, should anyone living in the home be prescribed this type of medication they could not be confident that their medication would be stored safely and securely. Care Homes for Adults (18-65 years) Page 20 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be confident that their concerns about how they are treated are listened to and acted upon as stated in the complaints and safeguarding procedures. Evidence: Since the last inspection the complaints procedure has been revised to include whistleblowing, bullying and harrassment. The manager stated in the AQAA, We have a comprehensive complaints procedure and POVA policy. Staff, service users and families are confident that they can speak to anyone they feel comfortable with about any aspect of the home, its running and its management. No major complaints have been recorded since the last inspection. Through discussions with members of staff it is evident that minor concerns are dealt with as and when they arise. We observed on the day of the inspection that people living in Mondial spoke confidently about what they were going to do and staff listened to them. People spoken with said that if they had any problems they could talk to staff about them. The homes processes around dealing with concerns and complaints could be improved if minor concerns were documented together with what actions were taken to resolve the concern. This would demonstrate that they listen to people and take anything that is worring them seriously, no matter how minor it may appear. Staff spoken with on the day of the inspection understood their responsibilities around Care Homes for Adults (18-65 years) Page 21 of 32 Evidence: recognising and reporting any signs of abuse. Personnel records contain evidence that staff undergo Criminal Record Bureau (CRB) checks. However, staff files did not contain evidence that staff had received formal training around safeguarding people (previously called Protection of Vulnerable Adults or POVA). At the time of the last inspection it was recommended that staff needed to be familiar with safeguarding adults protocols. This shortfall would be addressed if staff received up to date safeguarding training. Care Homes for Adults (18-65 years) Page 22 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can enjoy living in an environment that suits their lifestyle and which is well maintained and clean. Evidence: The manager stated in the AQAA, Mondial is a safe, clean, comfortable and inviting home with large pleasant gardens which service users and their guests have unrestricted access to. Peoples individual rooms are personalised with photographs, ornaments, books, televisions and music equipment. All individual bedrooms have ensuite facilities. The lounge is furnished comfortably but is slightly bare, with few items such as ornaments or pictures to make it more homely. Staff said that people living in the home prefer to keep things like photographs in their own rooms. However, the environment could be improved if there were some wall hangings, prints or pictures and some soft furnishings. A tour of the premises showed the home to be clean throughout with no unpleasant odours. The laundry area is small but contains equipment and facilities appropriate for the size of the home. A relative who completed a survey stated, on my visits the standard of cleanliness is very good. Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: The kitchen is domestic in nature and kept clean and tidy. One piece of equipment, an older toaster had scorch marks on the side indicating that the sides of the appliance get hot in use. The toaster had been tested as safe and had a PAT (Portable Appliance Test) sticker. However, modern toasters that have a cool wall facility would reduce the risk of someone accidentally touching the hot sides of the appliance. The manager stated in the AQAA, We have plans to improve the garden areas and some internal decoration. Care Homes for Adults (18-65 years) Page 24 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in Mondial can be confident that they are cared for by an established staff team who can meet their needs. Evidence: The manager stated in the AQAA, We have had the same three core members of staff for over four years, who have been working towards and gained NVQ qualifications. The deputy manager said that she is now about to commence an NVQ (National Vocational Qualification) level 4 management qualification. The deputy manager and carer who were working on the day of the inspection have been with the service for a number of years and there have been no new staff employed since the last inspection. Through discussion the deputy manager was able to demonstrate that they have now improved the recruitment process and they are aware of the requirements in regulation relating to appropriate documentation, which will be followed when any new staff are employed. Personnel files examined contain evidence of training in Infection Control, Food Hygiene, Moving and Handling. The deputy has also attended training around the Disability Discrimination Act, Staff Appraisal and the Freedom of Information Act. As mentioned earlier in this report, staff had not had up to date training around safeguarding vulnerable people. The deputy manager said that she is going to take a Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: course on death and funerals. The manager stated in the AQAA, staff training is going to be our main focus over the next year. We are going to explore other avenues of training, including distance learning. A relative who completed a survey stated, The feedback I get from my [relative] is always positive about the staff, the home and [their] care. People living in the home were seen to interact well with the members of staff on duty and it was evident that they felt comfortable when communicating with staff. Care Homes for Adults (18-65 years) Page 26 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall Mondial is run in the best interests of the people who live there but improvements in the day to day management would improve the quality of the service for people in the home. Evidence: The manager who owns the home has a number of years experience and has appropriate qualifications. The manager provided us with a completed AQAA but, as at the last inspection, stated in all but two of the outcome groups throughout the document, I do not feel we can improve upon this at this time and in the remaining two staff training is always a problem for us in this locality. However, at the time of this inspection there remain areas where there are shortfalls in the National Minimum Standards, some of which were identified at the previous inspection. Improvements need to be made in the management of Mondial if they are to be able to demonstrate that the service is managed in the best interests of the people who live there. On the day of the inspection we discussed the home’s Quality Assurance system with Care Homes for Adults (18-65 years) Page 27 of 32 Evidence: the deputy manager. Mondial has a process in place for seeking the views of people using the service and the evidence is recorded in the home’s Quality Assurance file. Records examined contain surveys that have been completed by people living in the home. The manager stated in the AQAA, service users and staff know that their views and opinions will be listened to and acted upon. It was evident from discussions with people living in the home that they are consulted and their wishes are taken into account. The Quality Assurance process could be developed further by collating the information gathered into a report that forms a development plan for the home. Staff spoken with were aware of their responsibilities around keeping people safe. Health and Safety risk assessments are in place around legionella and COSHH (Control of Substances Hazardous to Health) but they could be improved by containing more detail. Risk assessments are written in a general way that does not clearly identify the risk, the reason for taking the risk and the measures that need to be taken to reduce the risk. A sample of Health and Safety and maintenance documentation was examined and found to be in order. This included the Gas Safety certificate, fire extinguisher maintenance, electrical installation certificate and PAT (Portable Appliance Testing). Care Homes for Adults (18-65 years) Page 28 of 32 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No 1 Standard 6 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. Timescale for action 01/12/2007 Care Homes for Adults (18-65 years) Page 29 of 32 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No 1 Standard 20 Regulation 13 Description You must make suitable arrangements for the handling, storage, safe administration and disposal of medicines. Timescale for action 20/01/2009 This is so that people living in the home are safeguarded from harm. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No 1 Refer to Standard 6 Good Practice Recommendations The management team should continue to develop care plans so that they contain greater detail to ensure peoples needs are clearly identified. The management team should continue to develop the risk assessments that are in place so that they contain greater detail to ensure all risks are fully identified and measures put in place to minimise the risks. 2 9 Care Homes for Adults (18-65 years) Page 30 of 32 3 16 People living in Mondial should receive greater encouragement to take responsibility and be more involved in the day to day running of the home, such as helping with the cooking. This would enhance their lifestyle and raise self esteem. The care plans should contain greater detail about peoples healthcare needs and how they are to be met. Concerns should be documented as well as major complaints to demonstrate that they take minor concerns seriously and act on them appropriately. Staff should be familiar with and understand protocols around safeguarding people including what agency outside the home is responsible for investigating allegations of abuse. A review of staff training would establish what courses need to be updated and what other training may be required to ensure people living in the home are supported by an appropriately trained staff team. The manager should ensure that information requested by us at the Commission, including the Annual Quality Assurance Assessment (AQAA), is accurate and is returned within the stipulated timescale. 4 5 19 22 6 23 7 35 8 37 9 39 The manager should further develop the Quality Assurance system so that when they seek the views of people living in the home and other interested parties, the information is used to form a development plan for the home, which demonstrates that people’s views are being acted upon. When areas where there may be risks for people living in the home are identified, the manager should consider whether risk assessments in place contain sufficient detail to ensure they are kept safe. 10 42 Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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