Inspection on 12/11/07 for Mont Calm Folkestone

This inspection was carried out on 12th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mont Calm Folkestone 15/01/09

Mont Calm Folkestone 28/07/06

Mont Calm Folkestone 06/09/05

Mont Calm Folkestone 28/04/05

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

CARE HOMES FOR OLDER PEOPLE Mont Calm Folkestone 24/26 Earls Avenue Folkestone Kent CT20 2HE Lead Inspector Chris Woolf Unannounced Inspection 12th November 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000063034.V352643.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. DS0000063034.V352643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mont Calm Folkestone Address 24/26 Earls Avenue Folkestone Kent CT20 2HE 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) 01303 251600 01303 251000 Mont Calm Folkestone Mrs Bronwyn Elizabeth Parsfield Care Home 28 Category(ies) of Dementia - over 65 years of age (28) registration, with number of places DS0000063034.V352643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2006 Brief Description of the Service: Mont Calm is a care home providing care for up to 28 people over the age of 65 years with a diagnosis of dementia. The home is situated in an avenue, a short walk from the popular Leas area of Folkestone. There is a mainline railway station and local bus routes nearby. The current fees for the service at the time of the visit range from £377.38 to £520.00 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The home does not currently have an e-mail address. DS0000063034.V352643.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this report has been gained from an Annual Quality Assurance Assessment (AQAA) completed by the home, questionnaires returned by three residents and one visitor, and a site visit to the home lasting 7 ½ hours. The site visit was unannounced, which means that neither the staff nor the residents knew that it was going to happen. The site visit included meeting and talking with residents, visitors, a visiting professional, staff, and the Manager and Deputy Manager. The provider visited the home during the site visit and there was the opportunity to speak with him. The Manager showed us around the building. We observed the interactions between staff and residents; lunch being served; an activities session taking place; and medication being administrated. A variety of records were inspected, including care plans, staff files, quality assurance, and some safety records. What the service does well: The homes care plans are detailed and give good guidance to staff on how to meet the needs of the residents. The Manager is very pro-active in arranging activities and events for the residents and residents’ families help her in this. There is a friendly and welcoming atmosphere in the home. Staff treat the residents with respect A resident comment card included the comment ‘I am happy living here and have made friends’. A visitor comment card included the answer to the question, ‘What do you feel the care home does well?’ with the comment, ‘Everything - they are all absolutely superb’. A visiting professional commented, “It’s one of the best of all the homes I visit, the residents are really happy”. DS0000063034.V352643.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home mainly has good outcomes for service users. However, these have been compromised because of medication and environmental issues. Staff who administer medication need to take more care to ensure that all medication is properly stored when not actually being administered. The majority of issues about the home are in respect of the environment, which is looking uncared for and needs redecoration and some refurbishment. The individual concerns are detailed in the Environment section in the report. It is important that all staff receive up to date training in the Health and Safety related subjects and also that all staff receive training in Dementia and in the Protection of Vulnerable Adults. DS0000063034.V352643.R01.S.doc Version 5.2 Page 7 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. DS0000063034.V352643.R01.S.doc Version 5.2 Page 8 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 DS0000063034.V352643.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed prior to admission and can be confident that the home will be able to meet these needs EVIDENCE: The Manager, together with her deputy or a senior care worker, goes out to visit all prospective residents and carries out a comprehensive assessment to determine whether the home can meet the resident’s needs. Equality and Diversity needs are taken into account when doing the assessment. When a DS0000063034.V352643.R01.S.doc Version 5.2 Page 10 resident comes under the Care Management system a joint assessment is also obtained from the relevant Care Manager. The home will only accept residents whose needs they are confident of being able to meet. The home is registered to care for residents suffering from dementia. The Registered Manager is very experienced in dealing with residents with dementia and all staff working in the home have received training in dementia care. All admissions are initially on a trial basis. The length of the trial varies as all residents are individuals and as such some take longer to settle than others. This home does not offer the facility of intermediate care, which is a specialised service of short-term intensive rehabilitation to enable residents to return to their own homes. DS0000063034.V352643.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ general health and personal care needs are met but, to fully protect the residents, some improvements are needed to medication procedures. Residents’ privacy and dignity are respected. EVIDENCE: A detailed care plan is produced for each resident based on the information gained during the pre-admission assessment. Care plans include details of medical history, information on any equality and diversity needs including smokers or people who self harm, details of any allergies, and a variety of individual risk assessments. Incident reports are completed wherever DS0000063034.V352643.R01.S.doc Version 5.2 Page 12 necessary. Care plans are in use from the first day the resident moves into the home, and give sufficiently detailed information to enable the staff to care for the residents’ needs. The homes AQAA states, ‘Our care plans are very user friendly and informative. … This assists our carers to carry out their job more efficiently’. All care plans are reviewed regularly as a matter of course or sooner if the care needs change. Annual reviews take place with the Care Managers. The residents’ health care needs are met by the home supported by a multidisciplinary team of health care professionals. The homes AQAA states, ‘Most of our residents are unable to request medical assistance if required, our staff have a good rapport with all residents which allows them to understand each individuals needs and establish whether a GP, D/N, CPN etc is to be involved’. Records are kept of all contact with health care professionals. Nutrition assessments are completed and weights are recorded monthly. The home automatically writes to the G.P. if any resident looses more than 4lb in weight over the month, or if there is a regular pattern of weight loss. Where there is a danger of pressure areas developing the District Nurses are contacted and visit to give advice and guidance. The home has an aroma therapist who visits regularly. Residents are free to wander and get exercise within a safe environment. Resident comment cards included, ‘When I hurt my hand it was treated straight away’, and ‘Very happy with the care’. A visitor said, “They look after them well” The home has a clear medication policy and procedures. They do not keep any homely remedies and there are no residents who are able to look after their own medication. Storage of medication is generally good in locked cupboards in a locked room, but on the day of the site visit it was noticed that a box containing controlled drugs had not been put away securely. The Deputy Manager has undertaken to speak to the staff involved and remind them of the importance of correct medication practices. She will also increase her regular audits, which she normally undertakes weekly. A requirement has been made about this. It was noted that written entries on the Medication administration charts are currently not double signed and dated, and that the date had not been written on the labels of eye drops and liquid medication when they were opened. A recommendation has been made about these issues and the Deputy Manager is arranging for this to be done. The home has one medicine trolley, which is normally bolted to the wall when not in use. A second trolley is being obtained. The home is ordering a dedicated controlled drugs record book. Staff at the home uphold the privacy and dignity of the residents. This was witnessed on the day of the site visit and staff commented, “we try hard”, and “privacy and dignity here is good”. The homes AQAA states, ‘We promote the residents rights and their independence by encouraging them to do as much for themselves as they can’. DS0000063034.V352643.R01.S.doc Version 5.2 Page 13 DS0000063034.V352643.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a variety of activities to stimulate them; their visitors are made welcome in the home; they are able to make appropriate choices; and they receive wholesome and nutritious meals. EVIDENCE: The home has a very good activities programme. Each week there are activity mornings/afternoons and relatives or volunteers help the manager to organise these. They include games, artwork, and reading books and newspapers or having them read. Residents said, “I like doing this (activity)” and “I enjoy watching the activities”. Visitors commented, “We help with the activities”, and “They do a lot here”. Each resident has a personal folder that contains information gathered from his or her previous history, and photographs from DS0000063034.V352643.R01.S.doc Version 5.2 Page 15 the past. These folders act as a good reminiscence tool and the residents enjoy looking through them with their families or staff. Activities vary from a regular aroma therapist visit to playing skittles or basket ball, and cheese and wine afternoons to watching DVD’s. There are also daily 1:1’s. In the warmer weather residents sit out on the patio with carers and short walks are arranged along The Leas promenade. Several animals visit the home for residents to ‘pet’. The homes AQAA states, ‘We hold large parties throughout the year for our own residents and families and residents who live in our sister homes’. Photos of these events were witnessed and included Christmas, Easter, Valentines Day, Halloween, and Summer Garden Party. Residents comments included, “I enjoyed the party it was good”, “We had a Halloween Party it was really lovely”, and “I like the music”. Staff commented, “I’ve never worked in a home quite like it (for activities), its second to non”, and “Activities are fantastic”. A birthday party with hats, presents, cakes and cards is held for each resident. The home also holds a ‘Christmas lunch’ a few days before Christmas and invites the residents’ families to join them. There is a monthly communion service for those who wish to take part. Currently there are not any residents with different cultural needs but should other faiths be followed the home would arrange contact for the resident. The homes AQAA states ‘Mont Calm has an open house policy, all visitors are made welcome at any time of the day, and we encourage families and friends to participate in the residents daily living and activity requirements’. Visitors’ confirmed that they are always made welcome and staff commented, “We always give visitors cups of tea”, and “Visitors are welcomed, there are quite a few regulars”. Residents have choices in all aspects of their daily lives as far as their mental capacity enables them. The home’s AQAA indicates, ‘where the resident is able to make choices we encourage this’. Staff commented, “They do get a choice”, “They have a choice in everything possible”, and “We give choices but sometimes we have to make the decision for them in the end”. Residents receive wholesome and nutritious meals. The AQAA indicates - ‘We have set mealtimes, however the times are adaptable to suit the individual resident’s needs. Snacks and refreshments are available in between meals should any residents require them. Menus cater for all dietary/religious requirements. Likes and dislikes are obtained form the residents and taken into consideration. Staff are always close at hand to offer support and encouragement to any resident who requires help’. Residents were seen to be enjoying their meal on the day of the site visit and commented, “That was nice”, and “I enjoyed my lunch”. A resident comment card included ‘‘Just the right amount’. Staff commented, “Meals are very good, all home cooked”, and “The meals are quite good”. DS0000063034.V352643.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives know that their concerns and complaints will be listened to and acted upon. Residents are protected from abuse. EVIDENCE: The home has a clear and accessible complaints policy. A copy of the policy is on display in the home, and is also contained in the Statement of Purpose that is given to all residents and their families when they first move into the home. There have been no complaints about the home either recorded in the homes complaints register or reported directly to CSCI during the past 12 months. Comment cards from residents and relatives confirmed they knew how to make a complaint if this was necessary. Resident comment cards included the statements, ‘I always say what is on my mind’, and ‘I am happy. No complaints’. DS0000063034.V352643.R01.S.doc Version 5.2 Page 17 There have been no adult protection alerts on the home during the past 12 months. No member of staff is employed until a satisfactory check of the Protection of Vulnerable Adults register is received. At present not many of the staff have had training in the Protection of Vulnerable Adults and a requirement about this is made in the Staffing Section of the Report. DS0000063034.V352643.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is clean and reasonably comfortable, but considerable improvements are needed to the environment to fully meet their needs. EVIDENCE: There has been a requirement on last two reports that the grounds and outdoor space must be accessible and safe for all residents to use, including those in wheelchairs or with other mobility problems. On the day of the site DS0000063034.V352643.R01.S.doc Version 5.2 Page 19 visit the owner said he had looked at this and did not consider it possible to provide direct access from the home. He indicated that access could be gained to the garden area by walking around the home and coming into the gardens from an alternative entrance. As all of the residents suffer from dementia and several have mobility problems, this restricts their ability to enjoy the fresh air, as they are dependent on the availability of staff to take them out and to stay with them. The requirement is therefore repeated. Unless the owner can justify in writing the reasons for not providing the access, and can show how sufficient staff will be made available for the residents to be taken out when they wish, further action will be considered by the Commission. The homes AQAA states ‘If we had better access to our garden and private park we feel that the residents could benefit by being able to enjoy the warmer weather with walks, picnics etc’. The garden is looking much tidier than on previous inspections and the home now employs a regular gardener. There was a requirement on last report that risk assessments must be carried out with regard to individual residents accessing the patio area outside the staff room and these are now in place. The inside of the home is looking neglected and needs general redecorating throughout. There are areas where the fire alarm system was replaced some time ago where walls and ceilings have not been made good and decorated. There are security gates between floors which need painting or varnishing. The ceiling in the kitchen store needs to be repaired and repainted. Carpets need to be replaced in some areas before they become a trip hazard. A requirement made that a planned programme of works to upgrade the environment, together with timescales, is produced and is agreed by CSCI. . In each of the corridor there are open areas used for storage. It has been suggested during previous inspections that these areas should be enclosed to provide properly secured cupboard spaces. As this has not yet been done a recommendation is made regarding this. The home’s own quality assurance questionnaires raised comments on the décor of the home and a schedule for the replacement of residents’ beds, chairs, carpets and communal furniture is now in place. The home has two separate lounge areas, one on the ground floor and one on the third floor. There is also a dining room in the basement next to the kitchen. A shaft lift provides access to all floors Several of the toilet and bathroom facilities need attention or refurbishment. The 1st floor bathroom has damaged flooring that could be a trip hazard and paper from the ceiling was loose. There are two toilets on the 2nd floor, adjacent to one another and neither have hand wash facilities as the cubicles are too narrow; the decoration in these toilets is also poor. The 2nd floor bathroom décor needs attention and the ceiling is cracked. The downstairs toilets need to be decorated. An upper floor bathroom has been changed into a wet room. As yet this room has no heating and therefore cannot be used. DS0000063034.V352643.R01.S.doc Version 5.2 Page 20 The wet room also needs decorating and the tiling needs to be repaired. The 4th floor toilet flooring needs to be replaced and the room needs to be decorated and have the exposed pipes covered. The staff toilet in the basement also needs to be decorated. A requirement is made that all bathroom and toilets areas must be appropriately decorated and damaged flooring and tiles must be replaced. A recommendation is made that the toilet and bathroom facilities in the home should be reviewed to ensure they meet the needs of the residents, particularly the toilets with no space for hand wash facilities. Residents’ bedrooms are personalised to meet their individual needs and choices. Where there are shared rooms appropriate privacy screening is provided. Beds are gradually being replaced throughout the home. All of the bedrooms on the top floor need to have ceilings repainted and some also need repairs this is linked to the requirement for general redecoration. The home has a maintenance man but as he covers the maintenance of 6 homes it is impossible for him to keep up with the demands on his time. On the day of the site visit the home was clean and odour free throughout. Resident comment cards all confirmed that the home is always clean and included the comments, ‘Very clean, happy with my personal room’, and ‘My room is always clean’. Visitors commented, “It’s kept nice and clean”, and “There aren’t any smells”. The home has appropriate infection control procedures in place. DS0000063034.V352643.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service The care of residents is enhanced because they are supported by a team of staff who have been properly recruited and who are trained to meet their needs. EVIDENCE: Sufficient staff is employed on each shift to meet the needs of the residents. Staffing includes the manager and her deputy, care staff, domestics, cooks, kitchen assistants, and laundry assistants. In addition the home has a dedicated administrative assistant. The homes AQAA stated, ‘We have a low staff turnover; all staff have a good rapport with the management and their colleagues’. A staff member said, “We have time to do 1:1’s with the residents” DS0000063034.V352643.R01.S.doc Version 5.2 Page 22 Currently 64.7 of the care staff have completed their NVQ 2 or above in care. A further 2 are doing the training and 3 are starting NVQ level 3 next year. A staff member commented, “I have got NVQ 2”. The home’s recruitment procedures are sound and protect the residents. No new member of staff starts work until an Enhanced Disclosure from the Criminal Records Bureau has been applied for; and a satisfactory check of the Protection of Vulnerable Adults register and 2 satisfactory references have been received. The home is about to update all staff files to ensure that a full employment history is recorded for each member of staff. There was a requirement on the last report that there must be sufficient staff trained in First Aid to ensure that there is a member of staff trained in first aid on all shifts. This is now in hand with the final training booked for January 2008. There are some gaps in training for the Mandatory Health & Safety related courses, and also gaps in Dementia and Protection of Vulnerable Adults training and a requirement is made regarding this. Staff commented, “I have done dementia training”, and “I am doing moving and handling on Friday”. The home is currently updating their induction programme to meet the requirements of Skills for Care. General comments about the staff included a visitor who said “The staff are very nice” and a visiting professional commented, “The staff are really lovely” Resident comment cards included, ‘Always helpful and very kind and look after you well’. General comments from staff included, “I think it’s great, it’s one of the best homes I’ve worked in”, “The atmosphere is good”, “I think the residents get the very best we can offer them”, and “We work as a team” DS0000063034.V352643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents. The health, safety and welfare of residents and staff is protected. EVIDENCE: The Registered Manager has been managing Dementia Care services for over 10 years and holds an NVQ 3 in Care. Her deputy has NVQ 2, 3, & 4 in Care DS0000063034.V352643.R01.S.doc Version 5.2 Page 24 and the Registered Managers award and has been a deputy for a total of 5 years. Comments about the manager include a resident who said, “I think she is a treasure”. A visitor said, “The manager is great”. The manager operates an open door policy and there is a friendly and welcoming atmosphere in the home. Staff commented, “The office is always open”, “We get quite a lot of support from the manager”, and “She is very good about giving time off if we have a problem”. The home has developed its own quality assurance systems and sends quality questionnaires to families and staff annually. When the next questionnaires are due visiting professionals will be included in those surveyed. An analysis, Action and Improvement plan is being developed following receipt of the returned questionnaires. The home holds regular staff meetings; and regular audits are undertaken. There was a requirement on last report that the provider must produce a written report of monthly unannounced visits to the home in accordance with Regulation 26. This is now being done fairly regularly. The provider visits most weeks and asks the administrator to compile a report monthly. It was obvious from our site visit that the provider either does not do a full tour of the building, or that when he does he does not notice the works that need attending to. This is an important part of his responsibility. The quality assurance records included compliment letters to the home. One of these included the statement, ‘I am pleased and relieved that my mother is in such good hands and my mother seems to feel the same’. The only residents’ monies dealt with by the home are personal allowances provided by Powers of Attorney or social services. Documentation for this is sound, and the home presents the relevant documentation to each resident’s advocate. The home’s policies and procedures for health and safety protect both residents and staff. Maintenance of equipment is up to date. The home has written assessments on COSHH. Accident records are in order. DS0000063034.V352643.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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 3 1 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 3 DS0000063034.V352643.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 OP9 Regulation 13 (2) Requirement The storage of medication, particularly controlled drugs, must comply with the requirements of the Royal Pharmaceutical Society A planned programme of works to upgrade the environment, together with timescales, is produced to and agreed by CSCI. This includes all of the bedrooms on the top floor whose ceilings need attention in addition to the general maintenance needed throughout the home The grounds and outdoor space must be accessible and safe for all residents to use, including those in wheelchairs or with other mobility problems. This requirement is carried forward from the previous inspection - timescale 28/09/06 not met. All bathroom and toilets areas must be appropriately decorated; and damaged flooring and tiles must be replaced All staff must be trained and up to date in the mandatory training DS0000063034.V352643.R01.S.doc Timescale for action 30/11/07 2. OP19 23 (2) (b & d) 29/02/08 3. OP20 23(2)(o) 31/03/08 4. OP21 23 (2) (b & d) 18 (1) (a & c (i)) 29/02/08 5. OP30 31/03/08 Version 5.2 Page 27 courses, and in POVA and Dementia. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Written entries on the Medication Administration Records should be double signed and dated, and the date of opening should be recorded on the labels of all eye drops and liquid medication. The areas in corridors currently used for storage should be enclosed and made into proper storage cupboards. The toilet and bathroom facilities in the home need to be reviewed to ensure they meet the needs of the residents, particularly the toilets with no space for hand wash facilities 2. 3 OP19 OP21 DS0000063034.V352643.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local 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 DS0000063034.V352643.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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