Inspection on 06/10/05 for Montfort Fields 12

This inspection was carried out on 6th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Montfort Fields 12 22/05/09

Montfort Fields 12 13/04/07

Montfort Fields 12 03/02/06

Montfort Fields 12 02/03/05

Montfort Fields 12 21/09/04

Montfort Fields 12 25/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Montfort Fields 12 Kington Herefordshire HR5 3AT Lead Inspector Christina Lavelle Announced Inspection 6th October 2005 1:00 Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 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 Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 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 Adults 18-65. 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. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Montfort Fields 12 Address Kington Herefordshire HR5 3AT 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) 01544 231030 01544 231030 MacIntyre Care Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 residents with physical disabilities in addition to their learning disability may also be accommodated. 2nd March 2005 Date of last inspection Brief Description of the Service: The provider McIntyre Care is also a registered charity and runs many day and residential care services for children and adults with learning disabilities. Montfort Fields offers accommodation and care to five adults (men and women) who must be less than sixty-five years of age. Service users must require care due to learning disabilities and two service users may also have a physical disability in addition to their learning disability. Service users have a high level of need, which is reflected in the staffing levels at the home. Macintyre Care makes six promises to service users in its mission statement: • To listen and treat service users with respect. • To help keep service users safe, healthy and fulfilled. • To enable service users to make decisions about their life. • To encourage and challenge service users to achieve their ambitions. • To enable service users to take their place in the community. • To speak up for service users when they want them to. This care home is a detached house situated in a cul-de-sac in the market town of Kington. It is within walking distance of the town’s shops and facilities and the home also has two vehicles to provide transport further afield. Each service user has a single bedroom, three of which are large. The two ground floor bedrooms are adapted for people with physical disabilities (and so may need to use a wheelchair). There is a bathroom and shower on both floors and a separate toilet on the ground floor. The downstairs bathroom is assisted and so suitable for people with physical disabilities. The home has a large, enclosed garden with a summerhouse, which provides a very pleasant, private and secure place for service users. There is also a lounge, dining room and conservatory for everyone to use. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced inspection took place over four hours on a Thursday afternoon in autumn. The main aims were to check if the home continued to provide good quality care and whether the provider’s promises to service users were being met. The following ways were used to assess the service provided. Service users’ care, staffing and how the home was run were discussed with the manager. As service users have very limited communication (and so it was not possible to discuss their experience of the home with them) time was spent in their company and with staff members on duty. Comment cards were left at the home for service users’ relatives and visitors asking for their views of the care provided and about staffing and other aspects of the service. The feedback received is referred to in this report. A pharmacist inspector carried out a separate specialist inspection of the arrangements for handling medication. Stocks and storage arrangements for medicines, a sample of medication records, the medicine policy and procedures were all inspected. This inspection was carried out with the manager and the senior staff member with responsibility for medicines. The reports made by a representative of McIntyre following their monthly visits to the home to check the standard of care, also provided helpful information. What the service does well: Montfort Fields gives service users an opportunity to live in an ordinary house, which helps them to be part of the local community. The home is convenient to the town of Kington with its shops and facilities. The house is very homely and comfortable and is furnished and decorated to a high standard and kept safely. Staff were seen to be caring and supportive towards service users and clearly respect that it is their home. The atmosphere in the home was open, relaxed and welcoming. Comments received from service users’ relatives included: “ Staff have always had Xs best interests at heart. They are always enthusiastic and look after him very well. He seems very happy” and “ I feel the care my relative receives is excellent in all respects” Service users were enabled by staff to mix in the wider community and take part in a range of activities, which suited their individual needs and interests. Keyworkers help the support given to each service user to be more personal as staff work closely with them and their families and so know their needs and wishes better. Good attention was paid to ensuring all service users’ personal, health care, emotional and social needs were met. The home is very well run and the staff team have the skills and knowledge needed do their job properly. It was evident that the home’s promises to service users were all being kept. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 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. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard 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 The home provides appropriate information to help prospective service users and their families and/or representatives decide if Montfort Fields is where they might like to live and whether the home would meet their needs. Thorough assessment and admission procedures are in place to ensure that only people whose needs could be suitably met are cared for by the home. EVIDENCE: Mactintyre Care have produced all the required documents and the home had made them available to service users and relevant other people. They include a statement of purpose, service users guide and a service users agreement (contract). The guide is produced in a suitable format so that people with learning disabilities are more likely to understand them. Although no one had been admitted to the home within the last few years it was previously confirmed that comprehensive assessment and admission procedures were operated. The admission process (as was described) would include a careful and planned introduction to the home for new service users. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 A thorough assessment and care planning system helps staff to identify service users’ needs, goals wishes and know how to meet them properly. The person centred approach to care planning also means that significant other people in service users lives are fully consulted about their care and needs. Whilst service users’ ability to make choices and decisions is somewhat limited staff encourage their independence and self help-skills as much as possible. A thorough risk assessment process minimises any risks to service users and other people’s welfare and safety whilst taking account of service users’ rights. EVIDENCE: A sample of service users’ care records was seen. They included a pen picture, photograph and life story of each person. Also an individual communication profile; an assessment of all relevant care needs and a plan of care based on this information. The care planning system in place is appropriately person centred and so focuses on service users’ individual needs and preferences. The Keyworker system is very well developed and because service users’ level of disability Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 10 affects how much they can express their wishes and choices their families confirmed they are consulted to ensure their likes and dislikes are known. Families and important other people in service users’ lives were also involved in care review meetings, which the home tried to arrange six monthly. Plans seen had been reviewed at the specified interval and updated and also as any changes in need occurred. Keyworkers held monthly meetings to discuss and review their allocated service users’ care and progress. Service users are largely dependant on the support of staff and their families in exercising choice and for the protection of their rights and welfare, due to their profound disabilities. Relatives’ comments confirmed they are kept very well informed and involved in their family members care. Staff were seen to be respectful of service users’ and to offer any guidance and assistance needed in a very caring and sensitive way Risk assessments had been carried out in relation to service users’ personal activities and any areas that could pose a risk to their safety, such as bathing, managing money and should they go missing. When service users’ behaviour could have a disruptive affect on other people a behaviour management plan had been drawn up (with appropriate input sought from other professionals) which showed the possible risks and who and how should manage them. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 & 16 Service users were enabled by staff to lead active and interesting lives and to integrate within the wider community. Staff supported service users to maintain links with their families and significant other people in their lives. EVIDENCE: Service users all had an individual activities programme, which included their weekday day services and social outings as well as any interests, and hobbies they may like to follow whilst at home. Pictures and photographs had been used to ascertain where they would like to go and what they would like to do. Each service user took part in a wide range of activities, many of them within the wider community and staff time was allocated flexibly to support them. Whilst service users could not take up work related opportunities they went out most days and development of their artistic and self-help skills was promoted. The home provides two vehicles, one of which is a larger “people carrier” to facilitate outside activities. Holidays were also arranged to suit individuals. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 12 A tutor from a college takes session such as crafts and uses a local hall for a “Towards Independence” course. Other activities included an art class, animal petting, a social club for people with learning disabilities and horticultural class. Relatives confirmed they were always made welcome by staff in the home and were kept informed and consulted about their family member’s care. Care records showed very regular contact was maintained with service users’ families and some went home regularly for weekends and/or on holidays. Service users were encouraged to mix with other people and when friendships developed staff supported this and facilitated visits to and from them. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Appropriate arrangements were made to ensure the personal, health care, emotional and social needs of service users were identified and met. This included getting appropriate input from health care and other professionals. Consideration had been given to how staff should deal with a service users’ death. There is a sound system for the safe management of medicines with good monitoring by senior staff who demonstrated the attention to detail that is needed to help ensure residents receive the correct medication. EVIDENCE: Plans showed the assistance and support each service user needed for their personal care and to maintain good hygiene. Service users were observed to be well presented and dressed appropriately for their age and activities. It was evident from discussion with the manager and care records that service users’ health was closely monitored and their good heath promoted by staff at all times. This included annual health and other routine checks e.g. the dentist. Records were kept of all health related issues; medical input and when any specialist attention was needed. For instance one service user required a Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 14 particular diet and a Dietician had been involved in setting up an eating plan. Staff had also drawn up a separate menu, with records kept. Records were also kept in relation to conditions, such as epilepsy. The input of relevant health care and other professionals were sought, such as an epilepsy specialist. One service user had recently been in hospital and staff had persevered to get them appropriate treatment. Whilst this group of younger adults are relatively young it was evident that illnesses and health problems were closely monitored and would be dealt with appropriately. Families had been asked to discuss and complete a last wishes questionnaire in the event of a service users’ death. Medicines are stored securely and dispensed in a monitored dose system (MDS). Printed Medication Administration Record (MAR) charts are provided by the pharmacy. Changes or additions to the charts must be in a new section or a new chart with handwritten entries signed by a designated staff member and countersigned as a check for correct transcription. Discontinued medicines must be removed from the charts by liaison with the pharmacy. Most staff have attended two training courses provided by a pharmacist and are assessed as competent to administer medication within the home before undertaking this task. Designated senior members of staff should assess and sign the competencies. Further distance learning training is being sought. New members of staff must have this external training and assessments before being responsible for medicine administration alone. The authorised staff signature list needs the dates of joining and leaving included. Some staff have received training about emergency medicine administration by specialised methods. Other staff need more training for specific residents and some training updates will be due for some staff. There is a medicines policy and procedure information. These would benefit from a review to include specific local information for this home. Administration of medicines must follow accepted good practice guidelines provided. Information is in place for the use of prescribed emergency medicines for individual residents. Written plans should also be prepared for any medicine prescribed ‘as required’ so that all staff understand the intended use of such medicines for each resident. Information about the way in which residents are willing to accept medicines from care staff should be included in the care plan. This must ensure staff explain to residents when medicines are being administered. Consent from parents for medicine administration is not appropriate. There are regular audits of medicines that have previously identified some anomalies. These have been handled properly with action taken to reduce the risk of reoccurrences. The audits ensure medicines are used within the correct shelf life. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Effective systems were in place to manage complaints and to ensure that the health, safety and welfare of service users is promoted and they are protected. EVIDENCE: McIntyre provide an appropriate written complaints procedure. Although the current service users would be unable to use this procedure in a formal way it was evident that staff were very responsive to service users’ wishes and preferences and gave attention to ascertaining what these were. Relatives confirmed they were aware of the complaints procedure, although had never had to use it. The Commission had received one complaint about the service since the last inspection, which the provider had been asked to investigate. A thorough investigation had been undertaken and the response confirmed that the complaint was largely unsubstantiated, although one aspect of the homes procedures were revised to tighten up procedures at the home. There are adult protection policies and procedures in place, including whistle blowing. Staff receive regular instruction so they are aware of any possible indicators of abuse or neglect of service users and know how and where to refer any incidence or suspicion. Adult protection is also covered in the induction programme of new staff. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 Montfort Fields provides accommodation that is entirely suitable for the needs of service users and offers a very homely, comfortable and safe environment in a location which promotes service users’ community integration. Appropriate arrangements were in place to maintain and upgrade the premises EVIDENCE: The home is situated in a residential cul-de-sac near the centre of kington (a market town) and so there are shops and other facilities within easy reach. The house is an ordinary detached family house which has been extended into a former garage to provide an extra bedroom and staff sleeping-in room. It was evident there has been ongoing work (and so resources available) to maintain and continually improve the accommodation. The décor, furnishings, fritting and equipment are of very good quality. The environment provided is very homely and comfortable and was seen to be clean, tidy bright and fresh, which is commendable. The garden is fairly large and secure and is accessed by patio doors from the conservatory. It provides a very pleasant area for service users and the new summerhouse has improved the outdoor facilities further. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 17 The home offers a variety of communal areas, including a lounge, dining room and conservatory. Service users were seen to use them freely. There is a wellequipped kitchen and utility room with suitable laundry facilities. Service users have single bedrooms, which reflect their individual needs and interests and contain their personal possessions. The ground floor bedrooms have wide doors and are large rooms, which could be equipped for the needs of wheelchair bound and/or people with physical disabilities. There is a bathroom on both floors and the bathing facilities on the ground floor are assisted for people with physical disabilities. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 34, 35 & 36 Service users benefited from a suitably staffed home and by having a stable, competent and well-motivated staff team. This helps ensure the aims of the service are met and all service users’ needs are understood and met properly. Thorough recruitment procedures were in place to safeguard service users by helping to make sure that only suitable people work at the home. EVIDENCE: Service users are highly dependant on staff for all their care needs and it was evident from staff rotas that staffing levels reflected this and are far more than just adequate for meeting the individual and group needs of service users. The home was soon to be fully staffed. Two new staff had been appointed recently and another person was due to start at the home the next week. Staffing was appropriately rostered flexibly to support service users with their community activities and the home has a pool of regular relief staff to cover staff leave. The manager is supported by two senior staff who are delegated specific administrative responsibilities and share the management task. The staff approach was very service user focussed and seen to be respectful and caring. Staff clearly understood their role as a keyworker as part of the means to promoting individual service users rights and choices. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 19 It was confirmed by the manager that all staff must go through a thorough recruitment process. New staff are not deployed until a satisfactory CRB/POVA and two written references are obtained. A probationary period must also be undertaken before they are confirmed in post. McIntyre provides induction training for new staff which will meet with LDAF specifications and is accredited especially for people working in the learning disabilities care field. Twelve of the fourteen staff had achieved an NVQ qualification in care and the other two were doing NVQ training at this time. McIntyre also provide other relevant training opportunities for staff which are related to service users’ special needs, such as epilepsy and autism awareness. Some staff were due to do risk assessment training the following week. Each staff member has a personal development portfolio and staff received individual supervision six weekly from the manager or a senior. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42 & 43 Sound management systems ensure the home is run efficiently and so that service users receive good quality care. An effective quality assurance system is operated to monitor the service and to ensure it develops in accordance with service users’ needs and wishes. Suitably robust arrangements were in place to protect service users through maintaining a safe environment and by good working practices. EVIDENCE: The registered manager had recently left and a former manager of the home (Lindsay Ross) has been reappointed. Ms Ross is currently going through the registration process with the Commission and has substantial relevant experience and is suitably qualified for the role. The management approach in the home appeared to be open and positive. There were clear lines of accountability within the home and with the provider. McIntyre have been responsive to the inspection process and take a proactive Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 21 approach to supporting staff and service users. The manager receives regular supervision from her line manager and attends heads of services meetings monthly and quarterly training sessions. A representative of the provider also visits the home monthly as required. Following these visits reports are made on the conduct of the home, a copy of which is sent to the Commission. There is a quality assurance and monitoring system in place. This process appropriately includes questionnaires to be sent to relatives and other stakeholders to obtain their views of the service; more essential as service users would be unable to participate actively in this process. The outcome of this and the various audits undertaken should inform the planned and continued development of the service, for the benefit of service users. McIntyre provide a comprehensive range of required policies and procedures and the manager ensured staff used these to inform their working practices. These documents include a wide range related to health and safety. Monthly health and safety audits are also carried out by the home, which are reviewed regularly by McIntyre. Staff are expected to undertake all the mandatory health and safety training topics i.e. fire safety, first aid, moving and handling, food hygiene and infection control. Other aspects of health and safety checked included: • Checks on fridge and freezer temperatures were maintained. • Daily bath temperatures were taken and recorded. • Appropriate records of accidents and incidents were maintained. • Water was tested to prevent risks from Legionella. • Cleaning schedules were in place for staff. • The fire log showed the required tests/checks on the fire safety system and equipment were recorded as carried out at the specified intervals. • A written fire risk assessment was in place. • Vehicle checks were made regularly and recorded. • Monthly tests of all equipment were made and recorded. • An electrical system and portable appliance tests had been carried out. • Suitable insurance cover for the home was in place There were no issues identified that could adversely affect safety in the home during this inspection. It was evident overall that due attention and action was taken to promote the health, safety and welfare of staff, service users and other visitors to the home. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 X 4 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 4 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 4 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Montfort Fields 12 Score 4 4 2 3 Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X 3 3 DS0000024682.V259555.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13(2) Requirement The medicine policy and procedures to be reviewed and updated with specific information relevant to this home. Plans for individual residents to be completed for use of any medicine prescribed “as required”. Timescale for action 31/01/06 2 YA20 13(2) 17(1) 30/11/05 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 YA20 YA20 YA20 Good Practice Recommendations Residents’ consent to medication to be recorded. Handwritten entries on MAR charts to be signed and countersigned as correct by two authorised staff members. The British National Formulary to be updated to the September 2005 edition. Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN 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 Montfort Fields 12 DS0000024682.V259555.R01.S.doc Version 5.0 Page 25 - 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!