Inspection on 11/08/06 for Mont Calm (Sturry)

This inspection was carried out on 11th August 2006.

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 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 (Sturry) 17/09/08

Mont Calm (Sturry) 09/08/07

Mont Calm (Sturry) 06/09/05

Mont Calm (Sturry) 23/05/05

Mont Calm (Sturry) 19/10/04

Mont Calm (Sturry) 13/05/04

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

CARE HOMES FOR OLDER PEOPLE Mont Calm (Sturry) Star Lodge Park View Sturry Canterbury Kent CT2 0NW Lead Inspector Chris Randall Unannounced Inspection 11th August 2006 09:20 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 (Sturry) DS0000035711.V304156.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 (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mont Calm (Sturry) Address Star Lodge Park View Sturry Canterbury Kent CT2 0NW 01227 710897 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) Stephen Anthony Castellani Mrs Susan Hancox Care Home 16 Category(ies) of Dementia - over 65 years of age (16) registration, with number of places Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Mont Calm (Sturry) is a large detached house which has one shared room and fourteen single rooms. The home provides care for up to 16 people over 65 years old who have dementia. There are local facilities within Sturry and access to public transport, both buses and trains. There are parking places at the front of the building. There is a garden for residents use at the rear. The current fees for the service at the time of the visit range from £367 to £500 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 e-mail address of the home is via the provider at stephenmontcalm@aol.com Mont Calm (Sturry) DS0000035711.V304156.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 was gained from a pre-inspection questionnaire completed by the manager; comment cards received from Doctors, Care Managers, and visitors; and a site visit to the home. The inspection sire visit was unannounced and took just under 7 hours; it included talking to service users and staff, discussions with the manager, a tour of the building, observations, sampling of a meal, and inspection of records. What the service does well: What has improved since the last inspection? The requirements from the last report have been actioned, the service user guide has been revised and the planned information packs for staff regarding adult protection have been provided. The manager has passed her Registered Managers Award and NVQ Level 4 in care and has now been registered with CSCI. Paperwork and administration have improved with upgraded and improved care plans and other paperwork, a Welcome to Mont Calm book has been produced and a pictorial booklet is in the process of being produced. 6 bedrooms have been decorated, most of these have had new carpets and some have had new furniture. New garden furniture has been purchased. An extractor fan has been fitted in the kitchen. The upstairs bathroom has been refurbished. A new washing machine has been purchased, with the required Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 6 infection control programmes. A soap dish, towel rail, and splash back have been fitted in all bedrooms. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mont Calm (Sturry) DS0000035711.V304156.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 (Sturry) DS0000035711.V304156.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Prospective residents (and/or their representatives) have sufficient information to make an informed decision about whether Mont Calm (Sturry) is the right place for them. Residents moving into the home can be confident that their needs will be assessed to ensure they can be met prior to admission EVIDENCE: The homes statement of purpose has been reviewed and updated. In addition the manager has produced a ‘Welcome to Mont Calm’ booklet and is currently working on producing a pictorial booklet to take out to show prospective service users pictures of the home and its activities, when she undertakes their assessment. Each service user receives a contract but these need to be updated to reflect current good practice, in addition one of the contracts looked at had not been signed. A recommendation has been made regarding these issues. Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 9 Before the admission of any prospective service user the home carries out a comprehensive assessment to ensure they have the facilities and expertise to meet the service users needs. A joint assessment is also obtained for all care managed service users. No new admission is accepted until the home is confident of meeting the person’s needs. The homes registration category is for service users with dementia. The home does not offer the facility of intermediate care Mont Calm (Sturry) DS0000035711.V304156.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 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 good. This judgement has been made using available evidence including a visit to this service Residents’ care needs are set out in an individual plan that is monitored and reviewed to ensure that needs are being fully met. Residents are protected by the home’s policies and procedures for medication. Residents are treated with respect and their right to privacy is considered important EVIDENCE: Each service user has a comprehensive individual care plan which is reviewed monthly and quarterly. Service users weights are recorded monthly and significant changes are reported to the doctor. District nurses give support and guidance with service users who may be at risk of developing pressure area sores. The home operates a key worker system. Service users health is promoted. One G.P. response received included the comment, ‘This home provides very good quality care to a group of patients Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 11 who often present challenging problems of management’. Nutritional assessment is undertaken for all service users and information on nutritional management of dysphasia in the health care setting is kept in the kitchen. The manager has produced a new plan for care of the Terminally Ill and a mental health carers guide. A training course on eye care is being arranged. A comment on a Health & Social Care Professional comment cards reads, ‘The home has, in my opinion provided a very good level of care to a group of patients who often have challenging needs’, All professional comment cards received confirmed that they were satisfied with the overall care provided to service users within the home. However a visitor comment card stated, ‘mother is not always clean - finger nails and clothes’. The home has a medication policy and also has a homely remedies policy, although no homely remedies are stocked and the only medication administered is that prescribed by the service users doctors. The only fridge medication items stored are eye drops, prior to opening, and these are stored in a locked box inside the spare fridge in the staff room. A recommendation has been made that a dedicated, lockable, drugs fridge be purchased. Medication recording is in order and is sufficient to allow for an audit trail. All staff who administer medication have had appropriate training. Service users privacy and dignity are respected. Staff knock on doors before entering and call service users by their preferred name. Interactions between staff and service users were observed as friendly and relaxed but respectful Mont Calm (Sturry) DS0000035711.V304156.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 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. Service users social and cultural needs are supported and met; they are supported to maintain contact with family, friends and the wider community; they are given opportunities to exercise choice giving them a degree of control over their lives and they receive a balanced, wholesome and appealing diet. EVIDENCE: The home arranges a variety of activities to suit service users abilities and choices. Activities include a craft lady 3 days a week, Music and movement fortnightly, Aromatherapy fortnightly, Occasional make up sessions, song and dance, Knitting circle, Service users help to label socks, Old time sing songs, Group Coffee morning, there is an in house hairdresser who visits weekly, One staff member has planted sweet peas with service users. A pottery session is booked. . A service user commented, “activities – I enjoy a laugh and joke with everybody”, Staff commented “I do alphabet games, reminiscence pictures and 1:1’s with the residents”, “I chat, dance, I bring in my radio control cars, I took one client out to the model railway, and I bring in magazines and look at with them”, and “ I help with books, read letters & Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 13 postcards, chat 1:1, sing and dance”. Aids to orientation used include reminiscence photos displayed in the dining area with spot the face of film stars, they have also had sporting hero’s and famous army personnel; orientation board in the dining room which includes menu, weather, and staff on duty; there are photos on bedroom doors; and photos and examples of service users work are displayed in the hallway. Service users religious and cultural needs are supported, there is monthly holy communion for those who wish to partake and 3 service users go to church for special events. When asked how they maintain service users cultural and religious needs staff commented, “I would talk to manager and organise people to come in”, “the local priest comes in for communion. We have a bible in the home. Catholics are assisted with last rites. We did have a polish gentleman and we ensured he was able to celebrate Christmas on the day before as he did in Poland”. and “….. If requested we will contact other local religious leaders”. Visits from relatives and friends are encouraged and visitors are made welcome in the home. Contact with the local community is also encouraged. Some of the service users are taken to the local hairdressers weekly and have the opportunity of talking to their peers in the community; One service user who is interested in trains has been taken out to the railway; and the local mayor came in to judge the Easter bonnets. Service users are encouraged to mix with the other service users in the home. A staff member commented, “We encourage visits from family”. Service users are helped to make choices about their daily lives. On the day of the inspection they were witnessed choosing where to sit or walk, what to do, and what to have for their pudding. Meals at the home are wholesome, nutritious and attractively served. The cook has had nutritional training and is doing NVQ. A checklist has been produced for nutrition, and details of nutritional management of Dysphasia in the health care setting is in the kitchen. The menu is changed to reflect the seasons. Recently a sweet trolley, with three choices, has been introduced to enable service users to choose from things they see rather than what they are told. The cook is gradually introducing more choices into menu on the day of inspection one choice was cod wrapped in bacon which was very tasty, and all who chose this option were observed to be enjoying it. The cook commented, “I try to keep to a better balanced and nutritious diet, for example I avoid batter coated fish”. The cook keeps a record on what each person chooses and what is consumed. Currently the home caters for diabetics and for allergies of Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 14 shellfish, peanuts, cod, and lactose. A service user commented, “Food is very good”. Staff members commented, “The food is fine”,” I like the food, its quite good”, and “The food is good, it used to be boring but xxx has done a lot to improve things”. Appropriate assistance was observed for service users who needed help with their meals. Mont Calm (Sturry) DS0000035711.V304156.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 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 Service users and their representatives can be confident that their complaints will be listened to and addressed and that they will be protected from abuse. EVIDENCE: The home has a clear complaints procedure and a copy is displayed in the hallway. Copies of complaints forms are available for staff to use if needed. There have been no complaints since the last inspection. The requirement on the last report that the planned information packs for staff regarding adult protection has now been met, and the three staff spoken to all confirmed that they had seen this pack. 7 staff have done formal adult protection training and the others are still to be done, but all have been taught the basics and staff spoken to commented, “If I suspected anything I would go to the manager”, “I have seen it (information pack) and know I would go to the manager and to CSCI”, and “I have seen it (the pack) and we have adult protection and complaints forms available. I would report any abuse”. Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 16 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, 25, & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service Various health and safety hazards in the home and garden, and outstanding works required in the kitchen could put service users at risk EVIDENCE: The environment of the home is disappointing as there are problems that need to be addressed that could affect service users safety and the provider is urged to address these requirements without delay. Recommendations made by the Environmental Health officer in 2004 about works needed in the kitchen have not been actioned, and during his visit in August 2006 he indicated these have now been made a requirement. A requirement has also been made on this report to reflect this. Despite the requirements the cook manages to keep the kitchen clean and hygienic. Since the last inspection a new extractor fan Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 17 has been fitted in the kitchen. Currently access to the rear garden is not wheelchair friendly and involves going through the kitchen which is not acceptable, a requirement has made regarding this. Some new garden furniture has been provided since the last inspection and there are plans in place for further improvements to be made to the garden area. There is a Payphone available in the hallway, and photographs and examples of service users work are also on display in the hallway. The home has a stair lift to provide access to the first floor The homes communal rooms consist of a small lounge, a dining room where all service users can be accommodated, and a larger lounge fitted with a Television. The carpet in the large lounge is frayed along a join and could pose a trip hazard to service users. Although the manager has a quote to replace this carpet it has not yet been ordered therefore a requirement has been made about this. The home has two bathrooms; the downstairs bathroom has a Jacuzzi bath and a hoist for assisted bathing. The upstairs bathroom is not assisted but since the last inspection it has been refurbished. There are sufficient toilet facilities to meet service users needs. Service users bedrooms are personalised to meet their individual needs. They are encouraged to bring in some of their own belongings to make the rooms more homely and to aid orientation. A staff member commented, “Beyond their doors its their home. We like to see as many of their belongings as possible”. Since the last inspection six rooms have been decorated, most of these have been carpeted and some have had new furniture provided; also a soap dish, towel rail, and splash back have been fitted in all bedrooms. A service user commented, “my room is lovely”. There are no radiator covers fitted in service users bedrooms. As all service users suffer from dementia this lack of covers could pose a health and safety risk, a requirement has therefore been made regarding this. Push button taps have been fitted where these are considered safer for service users. On the day of the inspection the home was clean and there were no offensive odours although a visitor comment card received has stated, ‘ the home can frequently smell of urine’. Staff commented, “ The cleanliness is fine, we have a very good cleaner here and we (care staff) clean the basics at weekend and ensure there are no smells”, “The cleanliness is good. Xxx is an attentive Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 18 cleaner, does the little things like door handles”, and “The cleanliness is quite high, we try our best”. Since the last inspection a new washing machine with infection control programmes has been fitted. The home has appropriate infection control measures in place and staff confirmed they had received infection control training, one also said, “plus MRSA training”. Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 19 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 Service users needs are met by the numbers and mix of staff and they are protected by the home’s recruitment practices and training policies EVIDENCE: The manager uses the residential forum staffing guidelines when assessing how many staff are needed on duty. There are sufficient staff on duty to meet the needs of the service users. Currently the home has 80 of the care staff trained to NVQ level 2 or above. Staff commented, “No I don’t have NVQ but I have 19 years experience” “I am not doing NVQ because of my age”, and “I have Level 2 and am doing level 3”. Recruitment procedures are sound and protect the service users. No member of staff is started in the home until 2 written references have been received, an enhanced disclosure from the criminal records bureau has been submitted and a satisfactory check has been received against the protection of vulnerable Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 20 adults register. The manager is currently developing the homes job application form to include questions about Dementia. All staff have induction training when they are first employed in the home. Induction has been upgraded to the new Skills for Care common induction standards, enhanced to include specifics for the home. The manager is in the process of developing induction even further. Staff confirmed that they have had training in adult protection, dementia, fire, basic food hygiene, first aid, moving and handling, and infection control. A service user commented about staff, “They are so nice and kind”. A comment made on a G.P. comment card said ‘The staff, and particularly the matron in charge, Mrs. Hancox, are always helpful,, co-operative and thoughtful to the patients’. General comments from staff included, “I enjoy working here” and “Its lovely working here”. Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 21 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, 36, & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Although an efficient manager and an open culture in the home supports Service users, health and safety problems in the home could put them at risk. EVIDENCE: Since the last inspection the manager has completed her Registered Managers Award and NVQ 4 in care, and has been registered by CSCI as the Registered Manager for the home. The manager’s approach to the home creates a positive and inclusive atmosphere, and she communicates a clear sense of direction and leadership. A comment card received from a care manager stated, ‘ Manager at the home Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 22 gives good understanding re care of clients with xxxx needs’. All said spoken to said that the manager gave them support and one said, “very good support”. The home has quality assurance strategies in place. Questionnaires are sent to families and to visitors, but at present are not given to residents as all current service users are unable to complete them. However the manager will keep this under review. An annual development plan for the home is currently being prepared and a copy will be submitted to CSCI. Other regular audits include a general audit two monthly or more often if indicated; temperature checks; and Wheelchair checks. The homes procedures for looking after service users monies protect the service users. Monies are all securely stored and appropriately recorded, with receipts kept. All care staff receive formal supervision at least 6 times a year this covers all aspects of their practice and their training needs. They are also regularly observed in their work, and have annual appraisals. Despite the managers efforts to improve the home there are some safety risks that have been reported under environment, which the provider needs to take action to rectify. In addition not all of the health and safety certificates were available for inspection as they are not kept in the home but are with the provider. A recommendation has been made that copies of all health & safety certificates should to be kept in the home and available for inspection. A discussion was held with the Manager about statutory training. The manager had told staff that they had to update regularly but some of the older staff then spoke to the owner who allegedly told them that it was not necessary. Now it has been confirmed that updates are required she will ensure this takes place. A requirement has been made regarding this. The recording in the accident books was all in order. The fire logbook was in order, with all tests up to date. Staff have all had fire instruction within the last year. The home has a Fire risk assessment which was completed in October 2005; however the manager has recently received the latest update about fire risk assessments and has commenced a revised assessment.. Accident recording is in order. The homes current insurance certificate is on display Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 1 1 3 X X 3 1 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13 (4) (a) & 23 (2) (o) Timescale for action Arrangements should be made to 28/02/07 enable service users to have easy access to the garden and this access should not be through the kitchen as at present The kitchen improvements 28/02/07 recommended by the Environmental Health Officer in 2004 and now made a requirement should be undertaken The uneven areas in the garden 28/02/07 which could pose a trip hazard must be levelled The carpet in the lounge which is 30/09/06 frayed and could cause a trip hazard must be replaced In the interest of Health and 31/10/06 Safety all radiators and exposed pipework should be covered to prevent accidents The manager must ensure that 31/12/06 statutory training is in date for all staff Requirement 2 OP19 13 (4) (a) 3 4 5 OP19 OP20 OP25 13 (4) (a) 13 (4) (a) 13 (4) (a) 6 OP38 13 (4) & (5) Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 25 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 OP2 OP9 OP38 Good Practice Recommendations Service user contracts should be reviewed to ensure they all meet with Standard 2.1. All contracts should be signed The home should purchase a dedicated, lockable drugs refrigerator, with minimum and maximum thermometer and temperatures should be recorded daily. Copies of all health and safety certificates should be kept in the home and be available for inspection. Mont Calm (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 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 (Sturry) DS0000035711.V304156.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!