Inspection on 28/11/06 for Montague House

This inspection was carried out on 28th November 2006.

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

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

Other inspections for this house

Montague House 02/11/09

Montague House 19/03/09

Montague House 15/04/08

Montague House 25/04/07

Montague House 08/05/06

Montague House 17/10/05

Montague House 11/05/05

Montague House 19/01/05

Montague House 11/08/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Montague House Montague House 10 Brockenhurst Road Ramsgate Kent CT11 8ED Lead Inspector Christine Grafton Key Unannounced Inspection 28th November 2006 09:30 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 Montague House DS0000023499.V306278.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. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Montague House Address Montague House 10 Brockenhurst Road Ramsgate Kent CT11 8ED 01843 591907 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 Roy Edward Howse Mrs Susan Rule Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 2006 Brief Description of the Service: Montague House is a detached two-storey building with 15 single bedrooms and 2 doubles. 13 bedrooms have ensuite facilities of a toilet and washbasin; all rooms have a call bell and television point. There is a stair lift to the first floor. There is a large well-maintained garden to the front and rear of the building, providing a number of areas for residents to sit. There is an off-street parking area to the front. The home is located in a quiet residential area of the town, close to the cliff top promenade. The nearest shops and amenities in the town centre are within easy reach. Montague House admits people with low to medium dependencies. It does not accept people who have high dependency needs, such as those who cannot stand, who need lifting equipment to move them, or are wheelchair dependent for mobilisation. The home does accept people who use aids such as walking sticks and walking frames. The staff team work a rota that includes one person on waking duty and one person on duty sleeping in at night. Information provided by the manager in October 2006 indicates that the fees range from £303.25 to £409.00 per week and additional charges are made for hairdressing, chiropody and newspapers. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report takes account of information obtained from various sources since the last inspection, including written information received from the manager and provider, completion of a pre-inspection questionnaire and a visit to the home. An unannounced visit was made to the home on 28th November 2006 between 09.30 hours and 17.00 hours. The visit included looking round communal areas of the home and a selection of bedrooms, talking to the provider, manager, staff and residents, checking records and observing the interactions between residents and staff. The care of three residents was case tracked. At the time of the visit there were 17 residents. The inspection followed up on the things identified as needing improvement at the last inspection of 8th May 2006. As this was the second inspection this year, surveys were not sent out on this occasion, as they had previously been sent out to residents, relatives, care managers and doctors at the last inspection. Information in this inspection report indicates that the overall quality of this service is improving and the management arrangements are now adequate. What the service does well: The home provides a warm, welcoming, relaxed atmosphere. Residents each have a bedroom of their own and all but two have an ensuite toilet. Bedrooms are individualised with residents’ own personal possessions and some residents have brought in items of their own furniture. Several residents commented that their rooms are warm and comfortable and they enjoy spending time in them. Residents said that the staff are very nice, they treat them with respect and help them when they need it. Residents again made comments that the manager is easy to talk to and if they have any worries they only have to speak to her and she sorts it out. Residents are provided with a varied diet, they have a choice of food and the meals are well presented and served in pleasant surroundings. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The management needs to maintain the improvements made since the last inspection and continue to address the things identified as needing further work to provide a good quality service. These are important to promote and protect residents’ safety, welfare and best interests. Prospective residents should be given enough written information to help them decide if the home is right for them. This should include details about fees, arrangements for charging, paying for any additional services not included in the fees and how to make a complaint. Each resident should be provided with an accurate, legible contract, or statement of the terms and conditions of residency, so they know the room to be occupied, what service to expect, what their responsibilities are and those of the provider. Residents’ healthcare should be regularly reviewed with appropriate records kept to make sure that residents’ changing needs are properly addressed in their care plans. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 7 The activities programme should be further developed and formalised to make sure that activities are offered to meet the diverse needs of all residents. Each resident should be given their own copy of the complaints procedure so they can refer to it if needed. It should be written in plain language that is easy for them to follow. There needs to be a proper programme for the routine maintenance of the home and renewal of worn furnishings and equipment, to make sure that residents continue to be provided with a safe, comfortable, homely environment. Further attention is needed to ensure that the equipment provided and practices to prevent the spread of infection are sufficient to ensure the safety of residents and staff. The numbers and skill mix of staff on duty still need improving to make sure there are enough care staff on duty all of the time to meet residents’ needs. Although there has been some change in the outcomes for residents in this respect, the manager recognises the need to recruit more staff and indicated her commitment to this. Staff also need to be given appropriate training opportunities to improve their skills and competence. 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. Montague House DS0000023499.V306278.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 Montague House DS0000023499.V306278.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): 1, 2, 3 & 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is currently not enough written information provided for prospective residents to be able to make a fully informed decision about the service they will receive when moving into the home and how much it will cost them. The assessment process now adequately makes sure that a prospective resident’s needs are identified and any potential risks can be managed when they move into the home. The home does not admit people for intermediate care, so standard 6 was judged as not applicable. EVIDENCE: The statement of purpose and service users’ guide both need reviewing and updating to take account of changes and to ensure they include all the information specified in the regulations, to include details about fees, arrangements for charging and paying for any additional services not included Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 10 in the fees. The manager said she gives a copy of the service users’ guide to new residents or their relatives, but two out of the three new residents spoken to could not remember seeing this. One resident remembered being given a small coloured brochure about the home. Two contracts/statement of terms and conditions of residency were seen that both of the residents had signed. However the contracts were badly photocopied documents where some of the print was unclear. There were no details of the room number or arrangements for charging and paying for additional services. The fees were recorded for a privately funded resident, but there was nothing recorded about the method of payment for a resident whose fees were being met by local authority funding arrangements. Neither of these residents could recall having a contract. Case tracking confirmed that assessments had been carried out for new residents before they were admitted to the home. Copies of the care management assessments had been obtained and the home had completed its own pre-admission assessments. Improvements have been made since the last inspection to ensure that risks are properly considered and strategies put in place to reduce risk. The records on the whole provide a reasonable picture of the residents’ needs. The manager agreed to add personal profiles and more detail about the residents’ interests. Two new residents recalled their care managers talking to them about their needs before they moved into the home and said they were pleased with the care provided at the home. Montague House DS0000023499.V306278.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. Whilst the care planning system now provides staff with most of the information they need to meet residents’ needs, more attention is still needed to ensure all relevant health care details are recorded, otherwise residents cannot be assured that their needs will be fully met. Medications management, on the whole, promotes good health. Personal care is offered in a way that maintains residents’ dignity. EVIDENCE: The care of three residents was case tracked and the care plan of a fourth resident was also checked. The care plans showed signs of improvement since the last inspection. They are now arranged in an easy to read format and cover most of the components specified in the regulations and standards. Staff are now using the care plans as working tools and one carer has been given the task of updating them. This carer has some specific non-care time allocated on the rota for this purpose. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 12 The care plans provide instructions for staff on how to give the required care and include information indicating that residents’ health care needs are being monitored and action is taken to access health care services when necessary. However, daily records are still not detailed enough, for example, they do not always relate to the needs identified in the care plans, or include comments on activities undertaken. A review record completed by the manager provided a reasonable update where there had been a change of needs following a fall, but two other reviews gave no information at all about what had happened during the previous month, even though from discussion with the residents and staff there had been changes that should have lead to an update of the care plan. There was evidence that nutritional screening had been appropriately undertaken for a resident upon admission and subsequently, involving daily records of food intake and liaison with a community nurse. Weights had been recorded and the manager spoke of an improvement in food intake negating the need for intake records. However, this had not been recorded in the review records and the care plan had not been changed since the person was admitted. A resident described how they had fallen one evening and how staff had quickly assisted them, contacting a doctor who arranged treatment. The resident now needed more assistance from staff and praised the way that this is given, saying that their call bell is always promptly responded to and that staff give sensitive assistance with their personal care. The medication storage has been improved since the last inspection with the purchase of a purpose made medication cabinet of appropriate size. The medication administration records (MAR) were seen, and on the whole were appropriately recorded and up to date. The manager was asked to ensure that staff administering medications indicate the code for the reason a medication is not administered in a legible way. Although there is now a record of staff initials, some of the initials on the MAR sheets were inconsistent and the manager could not recognise them. The manager agreed to re-do the signatures/initials list and keep at the front of the MAR sheets for reference. A controlled drug had been prescribed for a resident and two signatures were recorded on the MAR sheet, but the home does not have a separate controlled drugs register to record receipt, administration and balance remaining. Six staff have completed a medication course. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst some residents have benefited from having improved opportunities to pursue leisure activities, this needs to be further developed and formalised to ensure that all residents’ social needs are met. Residents are encouraged to maintain contact with families and friends. Residents’ benefit from having a choice of food and well presented meals. EVIDENCE: A requirement was made at the last inspection to draw up and implement an activities programme. Although there is still no formal activities programme, a person has been appointed to work as a carer/activities person. Rotas indicate that the person does between 6 and 12 activity hours a week on one or two days a week. However, the activities person had been covering extra care hours on some weeks, leaving only one day a week for activities. The activities person was not on duty during this visit, but the manager gave some examples of activities, which she said are recorded in residents’ care Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 14 plans. Unfortunately because of the lack of detail in the daily records it was not possible to fully confirm this and no other activities records are kept. Two residents spoke of playing bingo and one resident spoke about doing exercises with the new activities person and of fortnightly film shows. Another resident has been doing ‘painting by numbers’. However, a resident spoke of their interest in card games and of wishing to have the opportunity to pursue this interest, which they said had been discussed with the activities person, but nothing had so far happened in this respect. Residents’ interests and social histories are not being routinely recorded in the care plans in any depth and these things might be missed. It was discussed with the manager that the activities person should keep a record of activities undertaken and for care staff to be encouraged to include them in the daily records. One resident regularly goes out into the local community for walks and another resident had gone out with relatives at the time of this visit. Several residents spoke about visits from relatives and friends and confirmed they are able to make choices. The lunchtime meal seen served was well presented and it was seen that there are alternative choices at each mealtime. The menus indicate a varied and nutritious diet. Several residents said they like the food and confirmed they have a choice. Montague House DS0000023499.V306278.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 adequate. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure makes sure that residents’ complaints are listened to and acted on, but residents would benefit from having their own written information to refer to on how to complain. Whilst arrangements for protecting residents are generally adequate, residents would be further safeguarded if staff were enabled to increase their knowledge and understanding of adult protection issues. EVIDENCE: The formal complaints procedure is displayed on a large notice board in the dining room and can be seen by residents and visitors to the home. A copy is included in the service users’ guide, but it is not written in very ‘user friendly’ language and the manager agreed to review and revise it. Residents spoken to could not remember being given their own copy of the complaints procedure. However, they knew what to do if they had a complaint and felt listened to and able to speak to the manager, or any of the staff, if they were not happy with their care, or any other services provided within the home. The manager said she generally resolves minor issues as they arise and that there had been no complaints since the last inspection. There is a policy and procedure in place on abuse and adult protection. A staff member indicated their awareness of the home’s ‘whistle blowing’ policy and confirmed they felt able to speak to the manager if they were concerned about Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 16 anything that might affect a resident’s well being. A recommendation was made at the last inspection for staff to be trained in the management of aggression, but this has not been achieved yet. Staff have not received any formal training on abuse and it was discussed that this should also be included in the staff training and development plan. Montague House DS0000023499.V306278.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the upkeep of the premises and overall quality of furnishings and fittings have provided residents with a more homely, comfortable and safer environment. Measures to prevent the spread of infection have reduced the risk of harm to residents and staff. EVIDENCE: A number of improvements have been made to the environment to address the requirements of the last inspection. Action has been taken to reduce infection control risks in the laundry with the fitting of a separate wash hand basin, new tiled flooring, washable work tops and new sink taps. Ten radiators have been guarded and the remainder are due to be completed soon. Worn armchairs have been replaced. A new ground floor extension has recently Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 18 been started, which will provide two additional single bedrooms and one double, each with an ensuite toilet. All areas of the home seen on this occasion were clean and warm. Residents have individualised their bedrooms with their own personal possessions and three residents said how much they like their rooms and enjoy spending time in them. Comments were also made about the comfort of the armchairs and about the new position of the television in the lounge. The manager said this change had been instigated at the residents’ suggestion so they all have a better view. At the last inspection a requirement was made for a written action plan to be submitted showing planned improvements to the building and to include a programme for the routine maintenance and renewal of the fabric of the premises. Although this was not forwarded, clearly a lot of work has been carried out and completed and the provider spoke of his intention to continue with the work started. There are still some things that are worn, or stained, such as the hall carpet, but the provider gave an undertaking to replace this when the extension is completed. Bathing facilities were again discussed, but the provider stated that although there is only one bath, as there is also a walk-in shower, he feels this offers enough choice. The manager has previously stated that the shower is never used. The lock still has not been repaired or replaced on the shower room door, but the provider said he would attend to this. Laundry procedures have improved. However, staff hand sluice soiled articles before putting them in the washing machine, as it does not have a sluicing cycle. It was discussed with the provider and manager that this places staff at risk of infection from airborne droplets, as well as possible contamination risks when emptying the faecal matter in a nearby toilet. The need for a sluicing facility was again discussed and the provider agreed to consider this in his improvement plan. Montague House DS0000023499.V306278.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 adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the numbers and skill mix of staff on duty in the home, if continued, should result in better outcomes for the residents. Recruitment procedures are on the whole adequate enough to protect residents and keep them safe. EVIDENCE: Requirements were made at the last inspection of 8th May 2006 for improvements in staffing levels, staff training and recruitment. Weekly rotas submitted since then have shown a gradual improvement, with the additional designated activities hours and sufficient ancillary hours for cooking and cleaning. However, although one new carer has been recruited, three have left and there is still a deficit in the number of care hours provided to meet residents’ needs. A new carer is currently being recruited and is waiting to start on completion of all the required checks. Even so, this only makes up for hours that existing staff are covering and will not sufficiently reduce the overall shortfall in care hours. The manager is also making up some of the care hours, leaving her less time to attend to her management tasks. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 20 Residents spoken to felt that there is usually enough staff to help them when they need it and that staff are good at their jobs. One resident spoke with enthusiasm about some of the activities they had been enabled to take part in with the new activities person. Three staff have completed their national vocational qualification (NVQ) level 2 in care and the manager gave details of short courses completed by staff during 2004 and 2005, covering first aid, moving & handling, infection control, fire safety and medication. However, none of the staff have attended courses on the recognition of abuse, adult protection procedures, or the management of behaviour. Two staff files were checked and it was seen that improvements have been made in the recruitment procedure and staff records. The manager has kept brief interview notes and full employment histories have been obtained. Staff files now contain most of the required information, including appropriate references and criminal records bureau (CRB) and protection of vulnerable adults register (POVA) checks. It was discussed to keep a separate interview record and also to keep a record of any discussions with potential employees where the reason to employ could be challenged. The manager has not yet devised a staff-training matrix, but indicated she discusses training needs with staff at their formal supervision meetings. Evidence of a first day fire induction and health and safety talk was seen in a new staff member’s file and the manager stated that they are currently working through their induction record book. Montague House DS0000023499.V306278.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, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the quality of this service is improving and the management arrangements are now adequate enough to promote and protect their safety, welfare and best interests. EVIDENCE: The manager stated she has completed all the components of her national vocational qualification (NVQ) in management and care level 4 and is just waiting for the final assessment. Since the last inspection of 8th May 2006, the manager has worked hard to bring about the improvements needed to address the requirements set. Although there is still further work to complete, evidence obtained in the last six months indicates the commitment of both the provider and manager to meeting the national minimum standards. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 22 The manager has recently sent out quality monitoring questionnaires to relatives and residents. She stated that the results would be summarised to provide written feedback to them. One relative had made a valuable comment for improvement that the manager said would be followed up. The provider has an improvement plan that involves the addition of the new extension, but this has not yet been formalised. The manager stated that residents are encouraged to manage their own personal monies wherever possible, with the support of relatives or other advocates. Where the home is involved, appropriate records of personal allowance monies are kept. Regular formal staff supervision is undertaken and written records kept. Following discussion at the last inspection, a staff member has been delegated responsibility for doing weekly walking route checks of the building for any environmental risks, or any maintenance repairs needed. Although a maintenance record book is kept, the walking route checks have not yet been recorded. Food safety risk assessment paperwork is currently being completed and the fire risk assessment was seen. Certificates were seen indicating that sufficient staff have been trained in first aid, fire safety, moving and handling and infection control. Montague House DS0000023499.V306278.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 2 2 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 3 2 X 3 3 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 3 2 2 Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4, 5 & 6 Requirement The statement of purpose and service users’ guide must be reviewed and revised to take account of changes and to make sure they include all the information specified in the regulations. Revised copies to be submitted. Each resident to be provided with a legible contract or statement of the terms and conditions of residency to include details of fees and additional charges as specified in regulation 5 (b)(ba)(bb)(bc)(bd). Service user plans must be reviewed in sufficient detail and updated when health and/or personal care needs change. The complaints procedure shall be appropriate for the needs of residents and each resident shall be supplied with a written copy of the complaints procedure. The registered person shall ensure that the premises are fit for purpose and residents live in a safe well-maintained environment. DS0000023499.V306278.R01.S.doc Timescale for action 31/01/07 2 OP2 5 31/01/07 3 OP7 OP8 OP16 15 31/12/06 4 22 31/01/07 5 OP19 23 31/01/07 Montague House Version 5.2 Page 25 The programme for the routine maintenance and renewal of the fabric of the premises to be continued. Action plan to be submitted specifying timescales for work to be completed. (Previous requirement 08/05/06 partially met and carried forward) Systems in place to control the 31/01/07 spread of infection must be in accordance with relevant legislation and published professional guidance. Procedure for sluicing of soiled articles to be reviewed and any necessary action taken to ensure safety. Any necessary sluicing facility to be provided. (Previous requirement 08/05/06 carried forward). There must be sufficient numbers of suitably qualified, competent and experienced staff on duty at all times to meet the needs of residents having regard to the size of the home. Evidence to be submitted. (Previous requirement partially met and carried forward) All parts of the home to be kept free from hazards and unnecessary risks to residents’ health, safety or welfare are identified and so far as possible eliminated. Records of the weekly walking route health and safety checks to be kept and environmental risk Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 26 6 OP26 13(3) 23 7 OP27 18 31/01/07 8 OP38 13(4) 31/01/07 assessments to be regularly reviewed and updated. (Previous requirement 17/10/05 & 08/05/06 partially met and carried forward). 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 3 4 Refer to Standard OP3 Good Practice Recommendations That personal profiles and details about residents’ interests are added to the assessments and care plan documentation. That some sit on scales are provided to monitor the weight of residents who are unable to stand unaided. (Carried forward from 08/05/06). That a separate bound controlled drugs register is obtained with numbered pages, to record receipt administration and balance remaining. That a staff signatures/initials list is kept with the medication administration records (MAR) sheets for reference. That the activities programme is further developed and formalised and records of activities undertaken by residents are kept. That bathing facilities are reviewed and any necessary action taken to ensure that sufficient numbers of baths are provided to meet residents’ needs. Lock to be repaired or replaced on shower room door. To keep separate interview records and to record any discussions with potential employees about any disclosures with the reasons for the decision to employ. That a staff training and development programme is devised and implemented. Staff training matrix to be forwarded. That the manager completes her national vocational qualification (NVQ) level 4 in management and care and DS0000023499.V306278.R01.S.doc Version 5.2 Page 27 OP8 OP9 5 6 OP12 OP21 7 8 9 OP29 OP30 OP31 Montague House 10 OP33 provides written confirmation to the commission. To develop and continue the homes’ quality monitoring process and to publish the results in the service users’ guide. Montague House DS0000023499.V306278.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Kent and Medway Area Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Montague House DS0000023499.V306278.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. 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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