Inspection on 28/08/07 for Montclair

This inspection was carried out on 28th August 2007.

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

The inspector 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

Montclair 01/01/10

Montclair 19/11/07

Montclair 22/05/06

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

CARE HOMES FOR OLDER PEOPLE Montclair 216 Banstead Road Banstead Surrey SM7 1QE Lead Inspector Barry Khabbazi Key Unannounced Inspection 28th August 2007 08:50 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 Montclair DS0000066309.V348974.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. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Montclair Address 216 Banstead Road Banstead Surrey SM7 1QE 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) 020 8393 7433 020 8393 7433 Mr Stephen Leslie Mann Mr Stephen Leslie Mann Care Home 10 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered up to 10 elderly people with mental ill health or dementia. 22nd May 2006 Date of last inspection Brief Description of the Service: Montclair is a residential home registered with the Commission for Social Care Inspection to provide care for ten elderly people with mental health needs. Montclair is a detached property situated in a residential road in Banstead. Each service user has a private bedroom with a wash hand basin. The home has communal areas on the ground floor consisting of a lounge, dining area and a conservatory that runs across the rear of the house. There is also a seating area in the entrance hall. The kitchen and laundry areas are clean and well equipped. Sufficient numbers of baths/ showers wash hand basins and lavatories are available throughout the home. There is a garden to the rear of the property and parking spaces to the front. The fees are currently £434 to £478 per week. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were assessed at this inspection. Additional non key Standards were also examined where shortfalls were identified under those Standards. This inspection was unannounced. During this inspection breakfast and staff interaction with the service users was observed. The manager/owner was interviewed. Records, care plans and the building were examined, as were the residents’ bedrooms. Although a number of minor shortfalls in meeting the National Minimum Standards were identified, no serious concerns were raised as a result of this inspection. See the requirements page and ‘what the home could do better’ section for details. A number of good practice examples were also identified and are recorded in the ‘what the home does well’ section of this report. The home was found to be generally well run with service users that are generally happy at the home, and staff were seen to treat the service users with kindness and respect. The owner/manager was open to constructive criticism, and demonstrated a willingness to meet the Standards well. I am therefore confident that any shortfalls identified will be met in a timely fashion. What the service does well: It is seen as good practice that the home does not manage any residents’ money and it is to be commended for pursuing alternative solutions. All residents have pressure sore risk assessments. This is seen as good practice as it could help avoid the development of pressure areas. The home has purchased its own items of pressure relieving equipment. This is seen as good practice as it will allow a fast initial response to any pressure areas discovered, while the resident is waiting to be assessed and provided with the pressure equipment they may need. The home has exceeded the required 50 of staff with a NVQ2 qualification. This provides a better trained workforce. All the above can have positive outcomes for the service users and are not specifically required under the National Minimum Standards. This was the first time the home has put forward examples of good practice and it is anticipated that further examples will be identified at future inspections. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Montclair DS0000066309.V348974.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 Montclair DS0000066309.V348974.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): Standard 3 and 6. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users sometimes move into the home without their needs being fully assessed. Standard 6 does not apply to this home as this home does not provide rehabilitation with a view to returning to the community. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home provides an initial assessment for new privately funded residents that cover all the elements required under Standard 3.3. The home’s own initial assessment is also made for residents who are placed through care management arrangements. As this is not specifically required for this group it goes someway to addressing the shortfall identified below: The latest new service user’s file was examined and did not contain a copy of the placing authority’s care plan and assessment. As this is required under Standard 3.2 the following requirement is now set. For individuals referred through care management arrangements, the registered person must obtain a summary of the care management (health and social services) assessment and a copy of the care plan produced for care management purposes. As other parties are also responsible for this {the placing authority}, this requirement could therefore also be met by the provider having a policy and procedure for chasing these which results in a complaint to the placing authority. This would prove that the home had done all it could to obtain the required information and shift the remaining responsibility onto the placing authority. Although there is a clear shortfall under Standard 3.2 it is tempered with the home’s own assessment. The rating for this Standard will therefore reflect this. Standard 6 does not apply to this home as this home does not provide rehabilitation with a view to returning to the community. Montclair DS0000066309.V348974.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): Standards 7, 8, 9, and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents’ personal and social needs are not recorded in their plans of care and therefore care plans do not inform staff of all of a resident’s needs. Residents’ personal care needs and physical and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is also well managed to ensure maximised good health Residents are treated with respect and dignity. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 11 EVIDENCE: Standard 7.1 requires a service user plan of care generated from a comprehensive assessment (see Standard 3) and is drawn up with each service user and provides the basis for the care to be delivered. Standard 7.2 requires that the service user’s plan sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Although the home’s care plans cover health needs they do not record any personal and social needs and therefore care plans do not inform staff of all of a resident’s needs. The following requirement is now set to address this shortfall A record of all of a service user’s needs and how they are to be met and by whom must be recorded in their plans of care. This must include social needs. Standard 7.4 states that service users’ plans must be reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. Plans of care were not reviewed and updated on a monthly basis. This is needed to ensure that changing needs are identified and recorded. The following requirement is now set to address this. Care plans must be reviewed on a monthly basis and updated with any changes identified. Residents are registered with a General Practitioner and files demonstrated appropriate access to other health care professionals. A record of healthcare professionals’ contact with residents is recorded in their files. Residents are assessed, by a person trained to do so, to identify those service users who have developed, or are at risk of developing, pressure sores. Opportunities are given for appropriate exercise and physical activity. Nutritional screening is undertaken on admission and subsequently on a periodic basis, a record maintained of nutrition, including weight gain or loss, and appropriate action taken. Good practice identified under Standard 8: All residents have pressure sore risk assessments, this is seen as good practice as it could help avoid the development of pressure areas. The home has purchased its own items of pressure relieving equipment. This is seen as good practice as it will allow a fast initial response to any pressure areas discovered, while the resident is waiting to be assessed and provided with the pressure equipment they may need. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 12 The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. All staff who administer medication have had approved medication administration training. Medication records were up to date. Medicines are currently stored in a metal cupboard attached to the wall in the kitchen. This is sufficient for the current medication used but a more proper medicine cabinet will be needed if any controlled drugs are used in the future. Guidance was also available in the form of a BNF {British national formulary} also stored in the medicine cabinet. Although not a nursing home, many of the staff are nurses and retain their specialised knowledge. Residents can self medicate subject to a risk assessment. Staff were observed to interact with service users with respect and dignity and demonstrated a good relationship with them. This was confirmed through discussions with residents and previous relative questionnaires. Personal care needs were addressed promptly, and in a fashion that maintained the respect and dignity of service users. Montclair DS0000066309.V348974.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s policies support visits to the residents from relatives and friends. Residents are provided with opportunities to remain part of the local community and are able to take part in appropriate activities. The daily routines and the home’s policies promote the residents’ choice and rights, to ensure equality and that all rights are enjoyed by all residents. Dietary needs are catered for and a balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: The routines of daily living and activities are made as flexible as possible, for example there is no set time for finishing breakfast. Residents are encouraged to maintain social contact with their peers through an open visitors policy. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 14 There is an open visitors policy and families are welcome to visit at any time, although the service users can choose who they wish to see. The visitors policy is included in the service user guide. Previous comments received from the families of the service users confirmed that they are made to feel welcome at his home. The home manager has introduced a bi-monthly newsletter to keep relatives and friends aware of what is happening at Montclair. There are seating areas around the home where visitors can sit and chat with their family member as well as in their bedrooms. Representatives from a local church regularly visit the home. The home has it’s own transport, to enable residents to undertake visits to places of interest locally. Community interaction includes the local town centre’s resources and shops. Residents are able to attend church should they wish to do so. Individual and group activities occur for example, nails and beauty, skittles, exercise, board games and crosswords. The home is run in a manner that promotes choice and independence and this was confirmed through residents’ comments, policies, and observation. The home does not take responsibility for the control or administration of any residents’ finances. Residents can bring in their own possessions and furniture if they wish and this was observed in their rooms, which had been individualised. Residents can take meals, and particularly snacks, at times and places to suit them and have a choice of meals and alternatives. Menus were examined and were nutritiously balanced. Breakfast was observed and staff were seen to provide support sensitively and with respect and residents were not rushed. Montclair DS0000066309.V348974.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): Standards 16 and 18.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are managed well which should ensure that residents’ and relatives’ concerns are listened to. The home’s policies and procedures help protect residents from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The home has not received any complaints since the last inspection. The complaints procedure was clear and contained all the elements required including a written maximum response time of less than 28 days and details of how to contact the Commission. However, the complaints procedure was in small print and not accessible to all the residents. Without this the desired outcome can not be guaranteed. The following recommendation is set to address this, The complaints procedure should also be produced in large print. In addition see Standard 14.1 which states that the registered person conducts the home so as to maximize service users’ capacity to exercise personal autonomy and choice. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 16 The home does not handle any residents’ money and there are lockable spaces in residents’ rooms and a safe for secure holding of valuables. The home has a copy of the local Adult Protection procedure. The home also has a Whistle Blowing Policy and a restraints policy. There is a Gifts Policy but the Wills Policy does not specify that staff are precluded from being involved in the making or being the beneficiary of a residents’ will as required under Standard 18.6. Infact it states the opposite. The following requirement is now set to address this: The home’s policies and practices must preclude staff involvement in assisting in the making of or benefiting from service users’ wills. Montclair DS0000066309.V348974.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): Standards 19, 21, 24, and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in very good condition externally and internally, and is well decorated in a homely fashion and very well maintained. This creates a pleasant environment that promotes the residents’ dignity and emotional wellbeing. There are sufficient lavatories and toilets but further protection from scalding is required at one sink. Residents’ rooms suit their needs but do not all contain all the furniture required under the National Minimum Standards or a record stating that the service user does not want it. The home is particularly hygienic and clean, homely and comfortable; this environment therefore promotes a pleasant environment, the residents’ health, and emotional well-being. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home has a lounge and dinning room, which are both large enough for all the service users to sit together if they wished. The home’s premises are in keeping with the local community and were suitable for their purpose. See also ‘brief description of service’. There are suitable bathrooms and toilets but one sink did not have a thermostatic mixer valve to reduce the risk of scalding but did have a hot water warning sign. In addition although there was evidence of the water temperature being checked during personal care provision, there were no records of this. These issues are also covered under Standard 30 health and safety, but will be recorded here under the washing facilities Standard for clarity. The following two requirements will be made here under Standard 21, to address the above shortfalls. 1, The manager must risk assess the urgency of fitting a thermostatic mixer valve and implement the findings of the risk assessment. 2, The hot water temperature measured during personal care must be recorded. The residents’ bedrooms were seen at this inspection. Bedrooms were decorated to a high standard. The bedrooms were highly personalised and reflected the individual tastes and preferences of their occupants. Almost all of the items required under Standard 24.2 were present although the two chairs required were not in all rooms. This is probably because of residents’ choice, but no records to clarify this were present. The following requirement is now set to address this: Bedrooms must contain all the items under Standard 24.2 unless risk assessment or recorded resident choice states otherwise. This will not negatively effect the outcome of Standard 24 on this occasion as rooms were well furnished and there was no evidence that residents could not have the extra chair if needed. The home gives the impression of a very clean and hygienic home. The building was clean and tidy and rooms were free of offensive odours. This has been the case at all announced and unannounced inspection visits. Laundry facilities have easily cleanable floors and walls. The home has policies covering storage, infection control and dealing with spillages. Hand washing facilities and protective clothing are available where required. Montclair DS0000066309.V348974.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency. The residents are supported by a staff group where 50 or more have the required qualifications. This raises the quality of staff, their knowledge and their practices. This Standard is exceeded. The staff vetting procedure does protect residents from undesirable staff. Induction and foundation training to National Training Organisation’s specifications is in place. This ensures a well inducted staff group. EVIDENCE: The home is managed and run on a day-to-day basis by the owner/manager, with assistance provided by staff. In addition to the registered manager there are a total of 13.5 full time equivalent care staff. The manager stated at the last inspection that at least 3 staff are always on duty. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 20 Standard 28 requires 50 of staff to have a NVQ2 by 2005. There are 9 staff with a NVQ2 out of a total of 13.5 full time equivalent care staff. This exceeds the minimum of 50 required and this Standard is exceeded. All of the staff recruitment records are in place. Criminal record bureau checks, proof of identity and references were available for inspection and met the required standard in files sampled. One staff photograph was missing on a file sampled. This is a minor shortfall and as the member of staff was previously known to the manager does not negatively effect the outcome. The Standard will therefore currently remain met. The following requirement is therefore only technically needed: Staff photos must be held on recruitment files. Induction and foundation training to National Training Organisation’s specifications is in place. Montclair DS0000066309.V348974.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 31 33, 35, 36, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a generally well run home. The home has implemented a quality assurance system and an annual development plan, with both involving residents. This should ensure that the home is run in a way that involves the residents and a way that is in the best interests of the residents. Residents’ financial interests are safeguarded by the home’s policies and practice. The frequency of recorded staff supervision falls short of the minimum of six sessions required. This could affect the quality of the work that staff do. Health and safety policies and procedures generally protect the residents. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has many years experience in the field and is a qualified nurse. The manager also has a certificate in management studies. This meets the required qualifications in both care and management. The manager also has other relevant qualifications, including a teaching qualification. Quality assurance tools currently include service user questionnaires, service user meetings and a complaints system. These quality assurance tools feed into the quality assurance system, which includes this information in the home’s annual plan where appropriate. The process then provides a system of feedback and review involving the service users in the form of resident meetings. This should allow open measuring of achievement in improving quality. The home does not hold savings for, or act on behalf of, service users. Evidence of good practice presented: The home is to be commended for pursuing alternative solutions regarding management of service users’ money. Staff files were examined and it was identified that supervision is occurring but this is not occurring with the required minimum frequency of 6 per year. One file sampled had only 4 in the last 12 months. The following requirement is set to address this shortfall: Formal supervision sessions must occur at least six times a year and must be recorded. As all the other Standards in this group are met and good practice was also identified, the shortfall will only reduce the rating of the relevant Standard {36} and not the whole group of standards on this occasion. Failure to meet this requirement however will represent a continuing and therefore growing shortfall and will reduce the whole management Standard if not met by the next inspection. All of the health and safety policies and procedures relevant to this Standard have been seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were available and these substances were all locked away. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 23 All of the procedures and annual testing of systems required in Standard 38 were also present except for the bacterial analysis of the water supply and tanks. This has previously occurred and has been assessed by this inspector as low risk, however the following requirement is needed. Bacterial analysis of the water supply must occur and then the manager must risk assess the required future frequency of this testing. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 x 2 x x 3 x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation Requirement Timescale for action 01/11/07 14{1}b d For individuals referred through Care Management arrangements, the registered person must obtain a summary of the Care Management (health and social services) assessment and a copy of the Care Plan produced for care management purposes. 15[1] A record of all of a service user’s needs and how they are to be met and by whom must be recorded in their plans of care. This must include social needs. Care plans must be reviewed on a monthly basis and updated with any changes identified. The home’s policies and practices must preclude staff involvement in assisting in the making of or benefiting from service users’ wills. The manager must risk assess the urgency of fitting a thermostatic mixer valve to the remaining sink and implement the findings of the risk assessment. { OP38} DS0000066309.V348974.R01.S.doc 2. OP7 01/11/07 3. 4 OP7 OP18 15[2]b 12[1]a 01/11/07 01/11/07 5 OP21 12[1]a 13[4]abc 01/10/07 Montclair Version 5.2 Page 26 6 7 OP21 OP24 12[1]a 13[4]abc 16[2]c The hot water temperature measured during personal care must be recorded. OP38 Bedrooms must contain all the items under Standard 24.2 unless risk assessment or recorded resident choice states otherwise. Staff photos must be held on recruitment files. Formal supervision sessions must occur at least six times a year and must be recorded. Bacterial analysis of the water supply must occur and then the manager must risk assess the required future frequency of this testing. 01/10/07 01/11/07 8 9 10 OP29 OP36 OP38 19 Schedule 2 01/11/07 01/11/07 01/12/07 17[2]b 1 8[2] 13[3] [4] RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard AD16 Good Practice Recommendations The complaints procedure should also be produced in large print. Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Montclair DS0000066309.V348974.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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