Inspection on 11/10/07 for Mont Calm Lydd

This inspection was carried out on 11th 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 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

Mont Calm Lydd 01/09/08

Mont Calm Lydd 11/03/08

Mont Calm Lydd 18/10/06

Mont Calm Lydd 05/10/05

Mont Calm Lydd 24/05/05

Mont Calm Lydd 24/11/04

Mont Calm Lydd 08/06/04

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

CARE HOMES FOR OLDER PEOPLE Mont Calm Lydd Manor Road Lydd Romney Marsh Kent TN29 9HR Lead Inspector Paul Stibbons Key Unannounced Inspection 11th October 2007 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mont Calm Lydd DS0000057128.V349527.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. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mont Calm Lydd Address Manor Road Lydd Romney Marsh Kent TN29 9HR 01797 321127 F/P 01797 321127 stephenmontcalm@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 Stephen Anthony Castellani Post Vacant Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2006 Brief Description of the Service: Mont Calm Residential Home, Lydd, formerly known as The Manor House, is a care home, registered for twenty-two older people with dementia. It is situated in the small coastal town of Lydd. There are some local shops and a church nearby. There is easy access, by road, to the larger towns of New Romney, Hythe and Folkestone. Currently the scale of fees is between £367.82 and £520 per week. Hairdressing, chiropody and toiletries are at an additional charge. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over a period of 8.5 hours and the acting manager was present. A range of evidence has been used to inform this report including information from other agencies, comments from two care managers and two relatives of service users. A completed Annual Quality Assurance Assessment (AQAA) was returned to the CSCI prior to the visit. Due to communication difficulties observation of service users’ experiences informs some judgements. A tour of the building was carried out and a variety of records and documents were examined. Discussions took place with the acting manager, head of care and staff on duty during the visit. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose and service user guide is in need of reviewing and updating to give accurate information to interested parties. Residents would benefit from more frequent meaningful and stimulating activities being introduced into the home. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 6 A suitable home vehicle would give residents the opportunity to access the community. A program of maintenance and decoration that is beneficial to people with dementia would improve the environment for those living there. The replacement of worn carpets and damaged furniture would make the home a safer place for people who live in the home and improve the environment. The introduction of regular health and safety audits would identify hazards to those who live and work in the home. People living in the home would benefit from a review of staffing levels to address additional requirements at times of peak activity. An effective quality assurance and quality monitoring system should be introduced to measure success against the statement of purpose. 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. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People considering moving into the home do not have the accurate up to date information they need to make an informed choice about whether the home will meet their needs. People have the opportunity to visit and a short stay to assess the quality and facilities of the home. Whilst residents benefit from the security of an individual written contract of terms and conditions with the home some improvements to the contracts are required to ensure clarity and transparency within them. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 9 EVIDENCE: The most recent registration certificate issued must be displayed in a prominent place. The home’s Statement of Purpose, Service User guide and individual contracts should be reviewed and updated to more accurately reflect the management structure and services available for people using the service. The home’s acting manager and the head of care confirmed that between them they assess prospective residents in addition to the assessments provided by care management prior to admission on a permanent basis. The four care plans viewed contained comprehensive assessments of residents’ needs and requirements. Residents are offered a trial stay of one month to assess the suitability of the home to meet their needs. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from having their health, personal and social care needs set out in an individual plan of care and they are supported to manage their medication in a safe manner. The physical and emotional health needs of people living in the home, is monitored with referral to other health care professionals when required. People living in the home can feel confident that the staff members will treat them with respect and support them to maintain their dignity. EVIDENCE: Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 11 Four individual care plans viewed were clear and easy to follow with evidence of having been reviewed on a monthly basis. A record of appointments with other healthcare professionals is evident, and ongoing health is monitored with records of weight, fluid charts, food etc. Risk assessments clearly identify the potential risks to residents and the controlling measures in place. There is evidence of these having been reviewed on a monthly basis. One resident is currently sleeping on a mattress on the floor for safety reasons. This arrangement is in agreement with the resident’s care manager and family. Documentation seen indicates that the CPN and other health care professionals are currently reviewing this arrangement. Records show that all staff administering medications have been trained and are competent to do so. Administration records viewed were completed appropriately and medication observed being given was in accordance with good practice guidelines. The staff members on duty during this visit were observed to be polite and caring to the residents and treated them with respect and courtesy. Individuals would benefit from staff members receiving training in supporting people with serious illness and care of the dying. Residents with en-suite facilities should have the choice to be able to wash and dress in their own rooms if they wish and are able. This is hazardous at the moment due to excessive hot water temperatures at hand basins. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home have little to occupy their time and would benefit from the introduction of meaningful and stimulating activity opportunities. People living in the home are supported in maintaining contact with family and friends. Whilst people living in the home receive a varied and balanced diet they would benefit from a record being kept of their likes and dislikes so that they are not offered food they would not choose to eat. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 13 EVIDENCE: During the visit several residents were having their hair done by a visiting hairdresser and one lady was looking at a book. Other than this no other stimulating activities were observed during the day. A sample of daily records viewed recorded little or no activities taking place. The acting manager states that an activities organiser comes to the home once a fortnight and a musician once every 6 weeks. The home does hold parties at times like summer, Halloween, Christmas etc and there are photographs of such events around the home. Relatives and friends are able to visit the home at any reasonable time. One visiting relative spoken with states that he believes his wife has only been out of the home once since moving in 3 months previously. Staff members spoken with state residents go out on average once a month in their wheelchairs and they do try to instigate activities with residents when they can find the time. The home does not have a suitable vehicle to take residents out and has to rely on the acting manager’s saloon car for health appointments. Lunch was observed and the meals looked appetising and good portions were served. Two members of staff were observed assisting residents to eat and were seen to treat the residents with respect and patience. However, one other resident was noticed having difficulty for some time in cutting their food into manageable sizes. When this was pointed out by the inspector the acting manager assisted the resident. This observation indicated that insufficient staff may not be available at mealtimes to meet all residents’ needs. Another resident was distressed and refusing to eat. When staff were questioned about the resident’s distress it was stated that it was because there were vegetables on the resident’s plate and the resident did not like vegetables. An alternative meal, minus vegetables, was offered which the resident ate. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 14 People living in the home would benefit from improved records and communication between staff, residents, families and catering staff, as to residents’ likes and dislikes or special diets. There was cooked food in the refrigerator and opened jars none of which had dates of opening on them. This could lead to spoiled food and pose a risk to residents’ health. Records viewed evidenced that refrigerator temperatures and meat probe temperatures had been taken and recorded. The storeroom was well stocked with foodstuff stored appropriately Menus viewed were varied and well balanced and the cook confirmed that the budget for food supplies was adequate. It was noted that an electrical socket was hanging loose from a wall in the kitchen and held in place by tape. This posed a health and safety hazard for staff and residents. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst people living in the home and their relatives can feel confident that their complaints are taken seriously and investigated not all complaints are properly recorded. Systems are in place to safeguard people living in the home from abuse. EVIDENCE: An examination of the home’s complaints policy and procedures indicated that they would benefit from being reviewed and updated to ensure information is current. Only one complaint had been recorded by the home since the last inspection. Following discussion with the acting manager it was confirmed that all complaints will be properly recorded in future. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 16 Communication difficulties prevent many of the people living in the home from raising concerns but staff spoken with and a visiting relative stated they would be comfortable in raising concerns on their behalf. A number of completed incident forms relating to one resident’s behaviour were viewed. There is no record of these incidents having been reported to the Commission for Social Care Inspection and in discussions with the acting manager it was made clear incidents of this nature must be monitored and reported to the Commission. There have been two adult protection alerts since the last inspection, one of which has now been closed with no blame apportioned to the home. The acting manager confirmed that all staff members have received training around safeguarding vulnerable adults. The acting manager was able to produce recent training certificates as evidence that the training had been carried out. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People living in the home do not have the benefit of living in a safe and wellmaintained environment. People living in the home have adequate personal and communal space to meet their needs but would benefit from attention to maintenance in some areas of the home. People’s access to suitable washing facilities is restricted due to damaged equipment and hazardous conditions. People have the specialist equipment they require to maximise their independence. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 18 EVIDENCE: A tour of the building concluded that residents do not live in a safe, wellmaintained environment. The main front door does not lock and is secured with a length of timber therefore compromising the security of the home. There is an inner door with a keypad lock to prevent residents wandering outside. A staircase reaches all floors but access is restricted for residents for their safety. There is a lift for residents to reach all floors of the home. A length of electrical cable for lighting in the hall runs beneath 2 doors and was chaffed and exposing wires, potentially placing people in the home in danger. The acting manager removed the cable immediately when it was pointed out. Carpets are badly soiled on the ground floor and the manager arranged an appointment to have them cleaned during the visit. The lounge has a music centre, television and comfortable seating for residents’ enjoyment. The ceiling in the lounge is showing signs of water damage and there is flaking of the paintwork above residents’ seating areas. There is a large bay window in the lounge but no curtains or blinds are up. People living in the home would benefit from attention to maintenance and the provision of curtains in this area. The dining area has good sets of tables and chairs but the carpet is soiled where food has been trodden in. An easy clean floor covering might be more appropriate and would be more hygienic for people living in the home. The laundry room is at the end of the ground floor corridor. This is a very small room housing washing machines and drier. The door has been sawn in half to resemble a stable door and would therefore not act as a fire door, potentially placing people in the home in danger. The acting manager was Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 19 unable to produce a fire risk assessment to check whether the laundry door is a designated fire door. Following discussion with the acting manager it was agreed that a fire risk assessment would be forwarded to the appropriate authorities for approval. The sluice on the ground floor has no cupboards or shelving and equipment is laid on the floor around the sluice. This potentially exposes people to the risk of cross infection. Advice from a cross infection nurse would benefit all who live and work in the home. On the first floor hallway the carpets are frayed and stuck down with tape in some places which potentially could cause of trips and falls for people in the home. People living and working in the home would benefit from replacement of the carpet and elimination of the hazard. Some of the residents’ bedrooms viewed are well decorated with personal possessions displayed; others are looking impersonal with broken furniture and drawers missing. In addition some rooms have holes in the walls where door handles have broken through the plasterboard. The safety and experiences of people living in the home would be improved by attention to maintenance and replacement of damaged furniture. There has been no portable appliance testing carried out on electrical equipment to ensure the safety of people living and working in the home. Specialist equipment is provided in the way of hoists, slide sheets, lifting belts and turntable. The hoists have been serviced as required within the LOLER Regulations. A discussion with two staff members about manual handling identified that they were unaware there were lifting belts to use and were moving residents bodily. The staff in question confirmed they have received manual handling training and a discussion was held with the acting manager to ensure staff are following their training to avoid putting both the residents and themselves at risk of harm. Hand basin taps in residents’ rooms run excessively hot with the potential to scald residents and it is a requirement that this is remedied with the utmost urgency. It was noted that in some bedrooms the hot tap is on the left facing the user and in others on the right. Water Supply Regulations in 2005 and 2006 state that the hot tap should be on the left facing the user. Although this regulation is not retrospective to installations prior to 2005 it would be Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 20 considered good practice to maintain consistency for a confused resident group. There are three bathrooms, one on the ground floor and two on the first floor. The bath on the ground floor has a large chunk broken off the side and is dangerous to use. This bath has been out of use since August 2007 when it was brought to the home’s attention by the inspector on a registration visit. With no usable bath on the ground floor, residents have to be transferred to the first floor if they require a bath. Attention to replacing the damaged bath would improve people’s experiences of personal care. One of the two baths on the first floor has some chips on the enamel surface that would benefit from being repaired to a more hygienic condition. Many of the waste bins viewed in en-suites and bathrooms had no lids on them and these should be replaced in the interests of hygiene and to reduce the risk of cross infection. Mont Calm Lydd DS0000057128.V349527.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living in the home would benefit from having more members of staff on duty to meet their needs at peak times of activity. People living in the home benefit from being supported by a staff team who are trained and competent to do their jobs. People are protected by the robust recruitment procedures of the home. EVIDENCE: Staffing rotas viewed show four care staff on duty in the morning, three care staff on duty in the afternoons, two waking night staff and one member of staff sleeping-in. Carers spoken with expressed the view that as the senior on shift is more often than not engaged in medication rounds and administrative tasks it was Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 22 difficult for staff to manage tasks especially as many residents required two persons to assist them. People living in the home are not supported by sufficient numbers of staff on duty to adequately meet their needs. Observations indicated that there are insufficient staff numbers to assist people who needed help in eating, to engage in stimulating activity or take people out for walks etc. Members of staff spoken with state that care workers have to attend to laundry and cleaning as well as personal care during the afternoons, evenings and weekends. People living in the home would benefit from the employment of designated laundry and cleaning workers to cover these periods. The acting manager is implementing induction training to “Skills for Care” specifications following a recommendation in the previous report to review existing induction methods. Training has been completed or planned for all staff in the areas they require to safely carry out their roles. The acting manager is arranging for training around care of the dying for all staff. AQAA dataset states that of the twenty one permanent staff, ten have NVQ Level 2 or above and seven are working towards the award. It is advisable that all staff in a senior position achieve at least an NVQ Level 3 qualification appropriate to their roles and responsibilities Four staff files viewed evidence that appropriate recruitment checks are carried out including two references and CRB/POVA checks. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of people living in the home is compromised due to a lack of health and safety awareness in the home. Clear auditable records ensure peoples financial interests are safeguarded. The care of people living in the home may be compromised because staff do not receive regular supervision. An effective quality assurance and quality monitoring system in place would benefit people living in the home. Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 24 EVIDENCE: There is no registered manager to run the home and the deputy manager has assumed responsibility for the day-to-day running of the home. The acting manager states that they will be submitting an application for registration in due course. The acting manager has achieved NVQ Level 4 in Care and the Registered Manager’s Award. The registered provider has not been conducting visits to the home and recording outcomes as required by the regulations therefore there are no Regulation 26 reports to view. Staff members are not receiving formal supervision on a regular basis, records viewed show the last dates to be in May/June 07. The acting manager states a formal structure for six times yearly will be put in place. Residents’ finances have a clear audit trail and monies are checked frequently. The acting manager was advised to make a written record of monies temporarily out until a receipt is returned. Policies and procedures that were examined were last reviewed in August 2007. People living and working in the home are at risk due to a lack of health and safety checks that would have identified the potential hazards mentioned throughout this report. The home’s acting manager was unable to produce a mains electrical test certificate, portable appliance test certificate and fire risk assessments, and confirmed that health and safety audits have not been carried out. There is no annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. Mont Calm Lydd DS0000057128.V349527.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 2 2 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 3 1 3 X 2 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 3 3 2 2 1 Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP4 OP1 Regulation CSA 28 6 (a) (b) Requirement The most recent issue of the registration certificate must be displayed. The registered person shall keep under review and, where appropriate, revise the statement of purpose and the service users guide; and notify the commission and service users of any such revision within 28 days. The registered person shall consult with service users about their social interests, and make arrangements to enable them to engage in local, social and community activities. The registered person shall give notice to the Commission without delay of the occurrence of any event in the care home which adversely affects the wellbeing or safety of any service user. The registered person shall ensure that all parts of the home are kept clean and reasonably decorated The registered person shall DS0000057128.V349527.R01.S.doc Timescale for action 30/11/07 30/11/07 3 OP12 16 (2) (m) (n) 30/11/07 4 OP18 37 (1) (e) 30/10/07 5 OP19 23 (2) (d) 30/11/07 6 OP19 13 (4) (a) 30/11/07 Page 27 Mont Calm Lydd Version 5.2 7 OP21 23 (2) (j) 8. OP24 23 (2) (b) (m) 9 OP25 13 (4) (a) (c) 10. OP27 18 (1) (a) 11 OP33 24 (1)(a)(b) 2. 3. ensure that all parts of the home to which service users have access are so far as is reasonably practical free from hazards to their safety. In this context damaged carpets, trailing electrical cables and insecure front door. The registered person shall ensure there are provided at appropriate places in the premises sufficient numbers of lavatories, and of wash-basins, baths and showers fitted with a hot and cold water supply. In this context this includes the damaged and out of use ground floor bath. The registered person shall ensure the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. In this context holes in walls of bedrooms and broken furniture. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. In this context excessive temperature of hot water supply. The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. In this context additional staff are on duty at peak times of activity during the day. The registered person shall establish and maintain a system for effective quality assurance and quality monitoring systems, based on seeking the views of DS0000057128.V349527.R01.S.doc 30/11/07 30/11/07 30/11/07 30/11/07 30/11/07 Mont Calm Lydd Version 5.2 Page 28 12 OP33 26 (1) 13 OP36 18 (2) 14 OP38 13 (4) (a) service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. Where the registered provider is an individual, but not in day to day charge of the care home, he shall visit the care home in accordance with this regulation. The registered person shall ensure that persons working at the care home are appropriately supervised. The registered person ensures the health and safety of service users and staff including fixed electrical installations and portable electrical appliances. 30/11/07 30/11/07 30/11/07 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 3. Refer to Standard OP11 OP15 OP26 Good Practice Recommendations Staff members would benefit from training around care of the dying. Service users preferences for food should be recorded to ensure their choices are met. Waste bins should all have lids for reasons of hygiene and to reduce the risk of cross infection hygiene. The sluice facility is untidy with equipment laid on the floor . Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection 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 Mont Calm Lydd DS0000057128.V349527.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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