Inspection on 05/12/05 for Montrose House Residential Home

This inspection was carried out on 5th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Montrose House Residential Home 13/10/08

Montrose House Residential Home 29/11/06

Montrose House Residential Home 06/03/06

Montrose House Residential Home 21/01/05

Montrose House Residential Home 06/10/04

Montrose House Residential Home 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Montrose House Residential Home 10 Renfrew Road Ipswich Suffolk IP4 3EQ Lead Inspector Mary Jeffries Unannounced Inspection 5th December 2005 14:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Montrose House Residential Home DS0000024452.V268932.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 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. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Montrose House Residential Home Address 10 Renfrew Road Ipswich Suffolk IP4 3EQ 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) 01473 710033 01473 710033 East Suffolk Mind Miss Katharine Farrow Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (8) Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st January 2005 Brief Description of the Service: Montrose House is a care home owned by the charity MIND and provides personal care and accommodation to ten people with mental health needs, eight of whom may be over 65 years old. At the time of this inspection eight of the residents were over 65. The home is located in a residential area of Northeast Ipswich, approximately two miles from the town centre. It is on a bus route. Accommodation is in a converted domestic dwelling with a newer extension and a shaft lift linking two floors. All bedrooms are single and two have en-suite toilet facilities. There is a lounge, conservatory and kitchen/diner. The home has a small car parking area at the front of the building and an enclosed garden, accessible from the conservatory, at the rear. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during one afternoon in December 2005. The Registered Manager was not on duty on the day of the inspection. The housing project manager and the assistant manager facilitated the inspection. Care staff on duty also contributed. There were nine residents living at the home at the time of the inspection, and another resident was due to be admitted the following day. Two residents were spoken with individually, and a group of residents were spoken with at the mealtime. Two residents were tracked. Daily notes of a third resident were inspected and the home’s incident log was inspected and discussed. The inspection took six hours thirty-five minutes. What the service does well: What has improved since the last inspection? What they could do better: Regular Regulation 26 reports must be provided. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 6 A of number modifications and / or improvements to the environment are required, including fitting a window restrictor to a large first floor window, dealing with stained carpets in the hall and living room, and providing a carpet for one resident’s bedroom. Resident’s protection must be enhanced by way of a comprehensive risk assessment for a resident who requires protection from another, and appropriate referral to customer first where abuse is suspected. A complaints log must also be maintained at the home. Temperatures must be taken and recorded of cooked meats. Wheel chairs must be regularly serviced. The home needs to provide details of all modifications and actions taken in response to the Fire Officer’s visit and report undertaken in February 2005. 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. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 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 Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, 4 Prospective residents can expect to have goods information available upon which to make an informed choice about whether they wish to live at the home. EVIDENCE: Following a requirement made at the previous inspection, the home had forwarded a copy of a revised Statement of Purpose to the CSCI. This document was inspected and found to contain the three elements previously identified as being required, i.e. 1. The arrangements in place for reviewing resident’s plans. 2. The sizes of rooms on offer. 3. Details of the registration (8 people over 65 years old and 2 people under 65 years old). The files did not contain single compass assessments. The assistant manager advised that residents who were on Care Programme, (CPA) came with a CPA care plan but not an assessment. One of the residents had been admitted from Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 9 another East Suffolk Mind home that no longer operates. They had an assessment from that home on file. The home conducts their own assessment; documentation is entitled housing application assessment form. A prospective resident had been assessed and was due to enter the home the following day. This resident was under 65 years of age, and this was not compatible with the registration as shown on the home’s certificate of registration. The core staff group were well qualified to meet residents’ needs. (See standard 30.) A carer spoken with had a good knowledge of their needs, as did the assistant manager and the home’s housing project manager. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 10 Residents can expect to be treated with dignity and respect by the home’s care staff, however it was not evidenced that all practical steps had been taken to reduce the possibility of another resident mistreating them. EVIDENCE: Care plans for two residents were seen to be in place and to have been reviewed in July, August, and October. One of these residents was under 65. Residents under 65 are on a Care Programme, and they confirmed that they saw the psychiatrist every 6 months. Once they are over 65 they no longer have a care coordinator, but a care coordinator had been obtained for one resident over 65 who was not happy with their placement. The assistant manager advised that a resident they were concerned about had had a full review involving the consultant psychiatrist, twelve days prior to the inspection, and medication had been changed and support provided. A record of this review had not yet been received at the time of the inspection. Residents’ files contained risk assessments, but the home’s housing project manager and the assistant manager confirmed that there was not a risk assessment for a resident who they were concerned was being emotionally Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 11 abused that detailed all of the risks that they described, or the remedial action that had been taken which they described. One resident advised that care staff help them shower, and go with them to the bank if they need some money. Residents confirmed that they had key workers. One described the key workers role as, “talking, and if you want anything done.” Three residents spoken with confirmed that they felt staff treated them with respect, and the housing project manager sought the permission of a resident before showing the Inspector the resident’s room. Medication administration was not observed on this occasion, but medicine administration records were checked for all residents and found not to contain any errors. Specimen signatures of those who administered mediation were on file. A pharmacist had inspected on 15th October 2005 and found no errors. One resident who is a diabetic, explained how they administered their own injections, with care staff observing. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15 Residents can expect to have considerable choice in their daily living routines, and to be able to welcome their family and friends into their home. EVIDENCE: Residents confirmed that they had flexible routines, and could exercise choice in their patters of daily living. One resident said they liked getting up at 6 to 6.30 am, another said they got up at quarter to twelve. One resident was seen clearing their own dinner plate, rinsing it and putting it in the dishwasher, but others did not and a carer advised that residents are welcome to help with daily routine if they choose. They advised that this also applied to laundry, that all laundry was done separately as the home’s policy was not to label clothing, and that staff usually do this but again residents could assist. After the evening meal on the day of the inspection one of the residents asked the carer on duty, “ Can I do something?” They were asked what they would like to do, and then helped get drawing materials. One of the younger residents could not think of anything that had improved, and regretted the loss of routine whereby one of the workers used to, some time ago, take them to football matches. They advised that they spend a lot of time going out, and go for a walk about four times a day to keep fit. Another resident said that Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 13 particularly liked watching the television and were looking forward to the good Christmas programmes. A carer advised that they thought every resident got some sort of holiday, at least two or three days. They advised that two had been to Cornwall. One resident said that they could go on a holiday, but didn’t want to, as they were a bad traveller. Another resident said that they had a holiday, and had gone with a carer. The carer on duty during the early evening said that during the summer there had been a number of days out, and that she had taken two residents to Felixstowe carnival. She also described how, if there are a couple of hours available, care staff would drive some residents to the garden centre. The carer contributed that both of the residents I was speaking with had their daughters to visit, and that if relatives who usually visit regularly have not been for some time, staff will enquire. One confirmed, “we can have them in our rooms or in here (the dining room)”. A member of staff advised that they tended to tell visitors to help themselves to a drink, and that one resident always makes a drink for their friend who visits on a weekly basis. A menu was displayed on the kitchen wall, displaying a well-balanced meal and choices. Two residents were asked what was for dinner did not know. A member of staff said that they could always ask. A resident advised that staff come round the night before and check what they would like to eat the next day. They said that the meals “ aren’t bad”, and particularly liked the main meal at lunchtime at the weekend. One resident said that “The food’s not great, but it’s better than St. Clements (hospital).” Another resident said that they regularly eat their evening in the garden in the summer, and like to have their evening meal later than most of the others. A carer advised that residents can, and do, help themselves to food in the fridge. There was a relaxed atmosphere at the time of the evening meal. The home’s freezer was well stocked, and food in the fridge was seen to be covered and dated. Coloured chopping boards were seen stored appropriately. The home had a locked cupboard under the kitchen sink for substances hazardous to health. There was no evidence of meat temperatures being taken, and the carer and assistant manager advised that the thermometer had broken. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 14 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 Resident’s felt able to complain and a resident who had complained recently had been properly responded to. EVIDENCE: One resident said that if they had a complaint they would go to Bob, (Bob Hawkins, the Housing Project Manager), and said that he comes to the home fairly regularly. Another resident confirmed that they knew how to complain, and said they would go to Mr Hawkins. This resident went on to say that they did not complain, explaining that they had been there many years and that the staff and managers were “all pretty sensible.” The home’s complaints procedure was seen, and was appropriate. A resident was spoken to who had recently made a complaint. This had been dealt with appropriately, and the resident was aware of what had been done to address their concerns. Although the situation they were concerned about had not been fully resolved, and could not be immediately resolved, they did not wish to make a further complaint at this time. This resident had asked for a care coordinator and this had been arranged. No complaint’s log was maintained within the home. The Inspector was advised “ we right them on paper and send them to (the RI)”. No complaints had been received by the CSCI in respect of the home in the previous twelve months. The homes housing project manager advised that they were concerned that one resident was emotionally abusing others, and particularly one resident also extorting cigarettes. The resident who had been witnessed to behave Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 15 inappropriately had been properly assisted as detailed under standard seven, they had also been written to stating that they were in breach of their tenancy. The project manager and assistant manager remained concerned about the subject of the behaviour, but as stated under standard 7, there was not a full risk assessment detailing all the risks staff and management were concerned about, nor, as the Inspector was advised, that knives had been removed from the resident who’s behaviour they were concerned about. The home had a recent copy of the local policy and procedure on the protection of vulnerable adults and had agreed to subscribe to this as their policy and procedure. This policy states that an abuser may another resident. No referral had been made to Customer First in respect of the issues described to the Inspector as abuse. The assistant manager advised that both she and the Registered Manager had attended training associated with the protection of vulnerable adult procedure adopted by the home. Evidence of a course undertaken on 20/09/05, provided by East Suffolk Mind and undertaken by both managers was seen. A copy of the Whilstleblowing policy dated 24/04/02, due to be reviewed April 2006 was provided. There was nothing in policy that states it is a duty to report if the concern is abuse, however, although there was a separate sheet in the policy folder that stated “ If you have any suspicion or knowledge of any of the residents being abused as defined in the Social care services policy you should inform the manager, or if you feel uncomfortable contact Social Care Services directly. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 The stained carpets, full ashtrays in the smoking area and vinyl flooring in two residents rooms detracted from the homeliness of premises, although residents rooms were otherwise comfortable, personalised, and well equipped. EVIDENCE: The home was basically clean and warm, but the carpets in the hall way and in the sitting room were badly stained. The home has a smoking room which had an extractor fan, but was very smokey and ashtrays were full. Two residents spoken with confirmed that they could have their rooms how they liked. Two residents’ bedrooms were seen. They were nicely decorated and personalised, and were fully furnished, however, the carpet in these rooms had been replaced with a wood block patterned non-slip vinyl. Staff advised that this was good quality and was a solution to continence problems. The residents’ occupying these rooms were spoken with, and advised that they could expect to have a good quality carpet that would cope with these problems if routinely cleaned. One of the residents said that they would prefer Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 17 a carpet; the other was very clear that they did not want a carpet and preferred to keep this vinyl flooring. The home had three toilets for communal use, in addition to two that are in en-suite facilities of ground floor rooms. One resident who had continence urgency problems required a commode, even though there was a toilet in close proximity of their room. The nature of their problem meant it was not covered. It was emptied twice a day by staff, but needed emptying at the time of the inspection. The rooms with en-suite facilities were used by residents with mobility problems, one of whom had been in that room for a long time. Two residents had wheelchairs for outside use. A Record of the serving of these were requested but not provided. The assistant manager provided a note to state that wheelchairs are checked by the Registered manager, and repaired if required. There was a large window on the landing of the first floor that was not fitted with a restrictor. A resident’s room was checked, with the resident’s permission, to establish the advice given that other first floor windows did have restrictors, and this was found to be the case in room 7. The housing project manager advised that the shower had been adjusted to maintain a safe temperature. The shower was tested and found, even at its highest position, to be close to 43 degrees Celsius. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 18 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): 27,30 The home has a well trained core staff group, that have good knowledge of residents’ needs and has continued to meet residents’ care needs despite staffing pressures. EVIDENCE: It was recommended at the last inspection that the role/position of cook be reviewed. The housing project manager advised that they believed a misunderstanding had occurred, as although a cook had been identified as something that they would like, they had never had one. The home’s business plan included obtaining a part time cook as an action towards an objective of accepting “more high care residents”, the housing project manager thought that this was unlikely to be achieved in the current climate of cuts to mental health services. The housing project manager advised that the home had two staff vacancies, one carer was due to start work on 2nd January 2006, the other did not yet have a start date as the home was awaiting a Criminal Records Bureau check and a second reference. They advised that pool staff were helping staff the home at present. The rota was seen for week 6, commencing 5th December 2005. This showed that the home normally provides two staff on duty at all times during the waking day, with an overlap of two hours during the day. At night the home has was one person awake and one person sleeping in. The rota for the week of the inspection showed that the home was running with some of the staffing shortfall being covered by the manager and assistant Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 19 manager, leaving less time for them to manage. The assistant manager confirmed this was the case. On the day of the inspection the assistant manager was working 14.00 hrs to 22.00hrs, and was covering a member of staffs duties that evening from 16.00 hrs to 22.00hrs. A similar schedule was in place for Tuesday 6th December and Thursday 8th December, with the Registered Manager on duty between 14.00 hrs to 22.00hrs, and covering a member of staffs duties that evening from 16.00 hrs to 22.00hrs, and for Friday 9th December, with the assistant manager covering. There were no obvious immediate consequences of this evident on the day of the inspection. The Inspector was advised that all staff had level 2 NVQ, and 50 had level 3. Certificates were seen for six of the seven (non pool) care staff, one was not on file. It was noted that one of the NVQs was in community health care. A carer, the assistant manager and the housing project manager, who is the direct manager of the Registered Manager all showed a good understanding of residents’ needs. Advice was also given that all staff receive manual handling training, and that this training was up to date. Three staff files selected at random confirmed this, both members of staff had received updates within the last two years, and one had a date marked for their next update in February 2006. The home’s manager’s file evidenced attendance at a full day risk assessor course. Other training including breakaway and responding to abuse and neglect was evidenced on other staff files. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 20 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, 37, 38 The home had conducted a quality control exercise and identified ways in which it intended to improve the service. Service user participation should be improved. EVIDENCE: Katharine Farrow had been approved by the CSCI as Registered Manager for this home since the last inspection. The home had forwarded a quality assurance report to the CSCI prior to the inspection, which had been completed in February 2005.The report gave outcomes of an “off the peg” QA manual which had been used as a blue print for Montrose House to be measured against, and concluded that these would be implemented and fed into the business plan. A business plan was provided. The QA report provided did not evidence consultation, with residents. Resident involvement in the running of the home was discussed with them. One said, Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 21 “We used to have meetings a lot, every week. … that keeps you more interested, it keeps you more involved. I’d like to see the meetings back.” Another resident said that they used to have meetings but hadn’t had one for quite a while. The assistant manager advised that they had planned a meeting for December 2005. Fire extinguishers were seen to have been recently checked. The housing project manager was asked what action had been taken in response to a report from the Fire Officer sent to the home in February 2005, following a visit to the premises. A copy of the report was not available at the home, but the works were described and shown to the Inspector. It was subsequently established that in the absence of a copy of the report to hand, not all of the fire officer’s requirements were described by the housing project manager, or therefore checked. The Inspector was advised that doors forming part of the fire resistance of the building had to be fire doors, and that a number had been replaced or intumescent strips fitted alongside the tops and the sides of frames. These were seen to be in place. The Inspector was also advised that door frames had to be repaired where these had been damaged by being forced open, and this was seen to have been repaired for some rooms, however their was slight damage on two others which the Inspector was advised had not been noted as requiring repair. The fire officer’s recommendation of extending the smoke detection was not discussed. The fire officer’s requirement to repair or replace the self-closure inn room 8 was not discussed. The Inspector was advised that risk assessments on individual rooms had to be in place. These were inspected and found to be generally satisfactory, but had not been signed. It was noted that the home’s fire risk assessment did not include smoking as a potential source of ignition in individual rooms. The home’s smoking policy states that no smoking is allowed in individual rooms. This was discussed and the Inspector was advised that staff try to ensure this is followed. It was subsequently established that the fire officers letter had recommended that the fire risk assessment, having previously found to be generic, be revised to take into account the specifics of the premises; i.e. the advice was not limited to individual residents rooms. The home’s certificate of Registration was displayed. Regulation 26 reports had not been received by the CSCI since March 2005. This was discussed, and the Inspector was advised that unannounced management visits are still undertaken, however, the last Regulation 26 report the home were able to provide was March 2005. A selection of policies were inspected, including the policy for dealing with violent or potentially violent situations and the restraint policy, and were found to be satisfactory. The home does not use restraint. Montrose House Residential Home DS0000024452.V268932.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 2 3 2 3 X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X X X 3 2 Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 23 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 OP4 Regulation 4 Requirement The home must not admit outside of the conditions of Registration. Timescale for action 05/12/05 2 OP7OP18 14(2)(b) A comprehensive risk 05/12/05 assessment detailing identified risks and actions that would be taken to minimise these must be undertaken in respect of a resident whose verbal statements have concerned staff. A complaints log must be maintained at the home. It must be established whether a PoVA referral is required in respect of a resident who is considered to have emotionally abused another. The carpet in the hall must be cleaned or replaced. Wheelchairs should be regularly serviced. A window restrictor should be fitted on the large window on the first floor landing. The registered person must replace the vinyl in one bedroom with carpet. DS0000024452.V268932.R01.S.doc 3 4 OP16 OP18 17(2) Sche4 12(1) 31/12/05 05/12/05 5 6 7 8 OP19 OP22 OP22 OP24 23(1)(a) 16(2)(c) 23(2) 31/03/06 31/01/06 31/12/05 31/01/06 16(2) (c) Montrose House Residential Home Version 5.0 Page 24 9 10 OP33 OP15OP38 26 12(1)(a) 11 OP3838 23(4)(a) 12 OP38 23(4)(a) Reports of monthly Regulation 26 visits must be provided to the CSCI. A meat thermometer must be obtained and cooked meat temperatures taken and recorded. Where there is any doubt that the homes smoking policy is not being complied with, a risk assessment should identify this hazard and the steps to be taken to reduce it, as part of the fire risk assessment. The home must provide a detailed written account of the actions taken to meet the recommendations and requirements of the fire officer in their report of February 2005. 15/01/06 31/12/05 31/12/05 31/12/05 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 Refer to Standard OP7 OP18 Good Practice Recommendations Care plans for older people (over 65) should be reviewed at least monthly. The whistle blowing policy should make clear that there is a responsibility to report abuse, and that in certain circumstances this properly be under the procedures outlined in the whistle blowing policy. Ashtrays should be regularly emptied in the smoker’s room. The resident who requires a commode should be offered an en-suite room when one becomes available. A record should be made on the file of a resident who wishes to retain the vinyl flooring provided that they wish to keep this flooring, which must be changed if another resident occupies the room. The frequency with which a service user’s commode is emptied should be reviewed. DS0000024452.V268932.R01.S.doc Version 5.0 Page 25 3 4 5 OP19 OP22OP21 OP24 6 OP26 Montrose House Residential Home 7 7 OP32 OP33 Regular resident meetings should be held, and residents consulted on how often they find these helpful. QA should be based on seeking the views of residents to measure the success in meeting the aims, objectives and purposes of the home. Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Montrose House Residential Home DS0000024452.V268932.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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