Inspection on 13/06/08 for Mornington Hall

This inspection was carried out on 13th June 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Mornington Hall 20/09/07

Mornington Hall 18/12/06

Mornington Hall 09/05/06

Mornington Hall 21/07/05

Mornington Hall 07/04/05

Mornington Hall 01/11/04

Mornington Hall 01/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Mornington Hall 76 Whitta Road Manor Park London E12 5DA Lead Inspector Sarah Greaves Unannounced Inspection 12:00 13 and 14th June 2008 th 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 Mornington Hall DS0000007363.V364527.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. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mornington Hall Address 76 Whitta Road Manor Park London E12 5DA 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 8478 7170 020 8478 6793 thompsmi@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Michalae Kathrine Ann Thompson Care Home 120 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60) of places Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 30 at Cornwell House 30 ELDERLY Mentally Ill at Haywood House 30 Elderly Mentally Ill Nursing at Hamfrith House 30 Nursing at Roding House Minimum Staffing Notice Date of last inspection 20th September 2007 Brief Description of the Service: Mornington Hall is a registered care home for older people, owned by BUPA Care Homes Ltd. The home is divided into four separate units; residential care, residential care for people with dementia, nursing care and nursing care for people with dementia. The home is located in Manor Park, within short walking distance of an over ground station and bus routes. There are car-parking facilities for visitors within the grounds of the home. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use the service experience good quality outcomes. This unannounced key inspection was conducted over two days. A Commission for Social Care Inspection pharmacist inspector accompanied the lead inspector on the second day of this inspection, in order to check the service’s compliance with a statutory requirement notice for medication issues that was issued in April 2008. We gathered information through speaking to residents and their visitors, and through observing staff interactions with residents. Information was sought through speaking to staff, including the registered manager, the deputy manager, the activities organiser, the chef manager, and nurses and care workers. We looked at a randomly selected sample of the care plans for residents, as well as staff records such as recruitment, training and supervision. The service was sent a self-audit document known as an Annual Quality Assurance Assessment (AQAA). Information from the AQAA was used as evidence for this report. What the service does well: What has improved since the last inspection? Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 6 Six requirements and two recommendations were issued to the service. Three of the requirements and one of the recommendations were issued as a result of a random inspection by two inspectors in February 2008, and the remaining three requirements and one recommendation were issued following a separate pharmacy inspection in the same month. It was noted that two environmental improvements had been achieved; keypads had been installed in the staff changing rooms and measures had been taken to eradicate odours in the sluice rooms. The service has evidenced that residents are being offered more opportunities to participate in community activities (and also meet younger local people). Significant improvements were noted with the management of medication. The three requirements and one recommendation from the pharmacist inspector have been deleted, although one new requirement and three recommendations have been issued in this report. Other improvements were found in the scope of activities offered to residents and the refurbishment of the premises. What they could do better: A requirement was issued in the previous inspection report for the service to ensure that the supervision records identified the issues that staff needed training and support for. Although supervisions records were now noted to address staff training and other required support, we did not find sufficient evidence to indicate that staff received sufficient one-to-one formal supervision (a minimum of six each year required). A requirement has been issued for the service to demonstrate that medicine records are accurate. Recommendations have been made for the management of the temperatures for medicine storage, improvement of the medication policies and procedures, and the identification of when medications have been commenced when expiry is limited by the period of usage. Please contact the provider for advice of actions taken in response to this Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 7 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. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents (and their representatives) are provided with comprehensively presented information about the care home and they are assured that their needs will be suitably assessed prior to admission. EVIDENCE: The Statement of Purpose and the Service Users Guide were viewed at a random inspection in February 2008; both documents were satisfactorily produced. At the time of this inspection there were ninety-nine residents at Mornington Hall; the vast majority of these residents had been placed at the care home via Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 10 the involvement of their local social services. We spoke to the deputy manager regarding the process for accepting a new resident, which included the receipt of assessments co-ordinated by the individual’s social worker and additional pre-admission assessments by a senior nurse at the care home. Prospective residents and/or their families were invited to view the service before moving in for a trial period. The service had developed protocols for the admission of people for short-term (respite) care. The key standard 6 was not applicable for assessment, as the service does not offer intermediate care. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are benefiting from improved care planning to identify and meet their holistic needs, including a more cohesive approach to monitoring and addressing health care. Although prior concerns regarding the management of medication have been resolved, other necessary improvements have been identified. EVIDENCE: We read nine care plans during the course of this inspection. Some positive improvements to care planning were noted during the random inspection in February 2008, and we found that this progress had been sustained. The service introduced a new care planning system known as ‘Quest’ late last year, which has provided staff with the foundation to develop more individualised Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 12 and detailed care plans. The registered manager stated that 10 of these documents were audited every month as part of the service provider’s internal quality assurance visit (the Regulation 26 monthly unannounced monitoring visit and report). There have been adjustments to the original system; for example, it was now compulsory for all residents to have a care plan to address their eating and drinking needs, whereas previously a care plan would have been developed in response to indications of actual or potential concerns obtained through research based clinical assessments and other observations. Other changes included sections for clearly identifying any known allergies and for assessing an individual’s needs in regard to the Mental Capacity Act. It was noted at the previous key inspection that the service needed to develop upon its knowledge of residents’ previous life history, particularly for people with dementia that would not be able to share information about their childhood, significant events, former hobbies and daily preferences. We found that good attempts had been made to complete the ‘life history’ section of the care plans, as well as the record of individual chosen routines (such as preferred time to get up in the morning and favourite bedtime beverage). We liked the inclusion of holidays taken, as this provided topics to promote one-toone and group discussions. We found that there was a positive difference in the terminology used by staff, which recognised the need to identify and record concerns about residents in a professional and sensitive manner. It was noted that an entry in one care plan read ‘X sometimes wets herself with urine’. This finding was discussed with the deputy manager, who was in the process of auditing all of the care plans on Heywood Unit. It was acknowledged that some staff needed further guidance with their care plans writing skills, which was being addressed. The deputy manager audited sixteen care plans each month and worked with staff to improve standards. We identified at the last inspection (and at this visit) that the care plans for the residential units inappropriately contained a front sheet with a blank space for the identification of the ‘named nurse’. The registered manager stated that this error had been brought to the attention of the central BUPA quality assurance department. We checked a care plan for a resident with grade 2 pressure sores on Hamfrith House. It was noted that the resident was a recognisably frail person upon admission to the care home, which was identified in the initial assessments. All of the documentation for the pressure sores (three separate skin tears) was up-to-date, inclusive of care plans, body map chart, photographs and three individual wound care charts. The resident’s file demonstrated that the associated care needs of the individual had been addressed, for example, the resident was supported to appropriately gain weight soon after admission, although weight loss had subsequently occurred. We also looked at a care plan for a resident with a pressure sore on Roding House. This resident was able to Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 13 discuss their health care needs and understood why staff encouraged compliance with the objectives within the ‘eating and drinking’ care plan. The detailed documentation within these care plans and other care plans read at the inspection indicated that staff were demonstrating better recognition of the importance of accurately recording all of their interventions (such as referrals to external health care professionals, notifying relatives of changes, provision of pressure relieving equipment and prompt adjustments to tissue viability assessments). The records completed by visiting professionals demonstrated that people were receiving private podiatry care or there was documentation that their needs were being met by Newham Primary Care Trust (PCT) podiatry services (this was applicable to residents with foot care needs that met the PCT eligibility criteria). There have been no reported issues of concern regarding the health care needs of residents since the last inspection visit. A statutory requirement notice was issued by the Commission for Social Care Inspection (CSCI) in April 2008, for the service to demonstrate that full and accurate medicines records were maintained, to enable audit of medications and ensure that that medication is administered in accordance with prescribers’ directions. This notice occurred following two visits by a CSCI pharmacist inspector earlier this year. The pharmacist inspector attended this unannounced key inspection and observed that there had been significant improvement, which satisfactorily met the issues within the statutory requirement notice. The following issues were observed at this inspection: 1) The policy for the safe handling of cytoxic medication needed further development. There were no cytoxic medications at the care home at the time of this inspection. 2) Four surplus tablets for a resident were found on Cornwell Unit, although the medication administration record for this individual indicated that all of the tablets had been administered. 3) Correct recording procedures need to be used when the pulse rate for a resident receiving digoxin indicates that their dose must be omitted. 4) Aqueous cream was prescribed for a resident on an ‘as needed’ basis. It was noted that staff were now applying the cream twice daily; this must be accompanied by the date of change and signed for accountability. 5) The use of aqueous cream had been discontinued but there was no recorded explanation, with a signature for accountability. 6) The temperatures within the medication storage rooms in Roding and Hamfrith Houses had exceeded the maximum licensed temperature of 25 degrees centigrade. Eye drops that did not require refrigeration were stored in the medication refrigerator on Hamfrith House. The pharmacist inspector has issued one requirement and three recommendations, which have been included in this report, and has advised the rating for this key standard. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 14 We spoke to residents (and/or their visitors) regarding how staff supported them to retain their independence and dignity. One of the visitors showed us a small garden area immediately outside of the resident’s bedroom, which had been allocated to the resident for her own gardening project. We identified a resident to ‘case-track’ during the inspection, although staff on the unit were not aware of our plans. We found the resident in her bedroom having a pampering session with two care-workers. This was a resident with physical health problems who was able to chat in a relaxed manner with staff. Observations on the nursing unit for people with dementia (Hamfrith House) identified how staff responded to engaging with residents with limited communication. We watched a care worker successfully encourage a resident to use sensory equipment. It was known that this resident might otherwise be withdrawn due to their dementia and other medical history, but has appeared to respond well to staff during this inspection and previous visits. Other observations during this inspection were positive, such as staff automatically knocking on bedroom doors before entering, even if it was known that the resident was in the lounge. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 15 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): 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. Residents are now being offered a wider scope of activities and more opportunities for social stimulation, which takes into account the different needs of people at the care home. A healthy and varied diet is provided. EVIDENCE: We met the full-time activities organiser, who was assisted by a part-time activities worker. There have been several new initiatives since the last inspection, including the purchase of equipment such as a garden shed, newstyle orientation boards for each house and interactive computer games played on television screens (sports and quizzes). The purpose of the shed was to encourage people to participate in gardening and outdoor activities; it was proposed to put in a refrigerator and radio to make it homely. The sensory garden had been completed. The cinema club took place twice a week in the quiet room in Roding House and was open to residents in other units; there Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 16 was also portable equipment so that a resident could borrow a film to watch in their own room. We looked at other activities items such as arts and crafts, musical bingo and large magnetic board games. There has been a good effort to enable residents to meet younger people in the local community. The care home had developed active links with Newham Sixth Form College; we observed social care students chatting to residents as part of a structured placement at Mornington Hall. There were plans for students of art, media and landscape gardening to offer their skills, including projects to create murals in the hairdressing salon and paint bedroom doors to re-create familiar memories (relatives had been asked to provide descriptions or photographs of the front door of a property that residents’ would regard as ‘home’). We found that the two houses for residents with dementia provided tactile objects that residents could pick up as they wished, and all houses were provided with an activities cupboard. The activities organiser had selected items for each cupboard, in accordance to the needs of the residents. Hairdressing by a visiting hairdresser was offered, which was a popular activity. Discussions with visitors demonstrated that visiting hours were flexible and visitors felt welcomed. We were informed that a Roman Catholic nun visited the home once a week. A room was provided for residents that wished to meet in a collective setting or people could be seen individually in their own rooms. Residents could arrange private visits from religious ministers and/or other representatives of their faith. We have considered whether some residents from non-Catholic backgrounds would like to receive weekly or monthly visits from a local minister or lay volunteer from another denomination(s); possible interest in this should be investigated. The registered manager stated that the service proposed to set up a residents’ committee for menu planning and staff recruitment, although this had not yet commenced and will be monitored for progress at the next inspection. Residents, relatives and friends were invited to attend regular meetings chaired by the registered manager; minutes for these meetings were provided. It has been noted at previous inspections that residents have been supported to use their civic rights, such as voting or retaining their attendance at external day centres. We joined residents for lunch on the second day of this inspection. It was noted that all food items were kept at their right temperature apart from the chips, although new equipment for cooking the chips was planned. We met the catering manager to discuss the menus, in addition to looking at the food stores in the main kitchen and in the kitchenettes on each house. We found that the menu plan was very flexible, including choices at each mealtime and a range of foods that could be chosen if people did not want the daily menu Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 17 choices. Between ten and eighteen residents regularly chose a cooked breakfast and there was a ‘night menu’ for people that wanted a more substantial snack in the hours after suppertime. We spoke to one resident (and their visitor) that used the night menu to help manage their needs as a diabetic. Fresh fruit was sent to each house three times a week and homebaked items were offered at some afternoon teatimes or as a pudding. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 18 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service demonstrated appropriate measures to protect residents. EVIDENCE: The service’s complaints procedure was viewed at the previous key inspection and found to be satisfactory. No issues of concern have been identified with the service’s own investigation of complaints. The Adult Protection procedure was satisfactorily produced and staff had received Adult Protection training last year (provided by the Newham Safeguarding Adults Team and internal training). There have been no issues regarding the protection of vulnerable residents since the last inspection visit. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 19 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): 19,24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with attractive and comfortable communal and personal areas. EVIDENCE: Mornington Hall is a purpose built care home, which is divided into four separate 30- bedded houses. There has been a major programme of refurbishment in recent months; this work was continuing at the time of this inspection. In addition to re- painting and providing new carpets, the service Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 20 had invested in new equipment such as profiling hospital beds (for the nursing units), reclining chairs, footstools and armchairs. As previously noted at the random unannounced inspection in February 2008, we noticed that the bedrooms we visited demonstrated good evidence of being personalised to reflect the preferences and backgrounds of the residents. We were informed that the current refurbishment programme has included the repair of existing furniture and the purchase of new items for all bedrooms. The bedrooms looked at on this occasion were pleasantly maintained. The care home was found to be clean and free from any lingering offensive odours. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 21 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): 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. Residents are supported through receiving care from safely recruited and appropriately trained staff. EVIDENCE: We discussed the staffing numbers and skills mix with the registered manager, and looked at staffing rotas on two of the houses; it was noted that the staffing numbers and skills mix was satisfactory. At the time of this inspection over 50 of care staff were reported to have a National Vocational Qualification (NVQ) in Care at a minimum level 2 or above. Opportunities for relevant NVQ training were also utilised by housekeeping staff. We checked the recruitment practices within four staff files (two registered nurses and two care workers); no issues of concern were identified. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 22 Training within the care home was discussed with the registered manager and we also spoke to the deputy manager regarding the more specific area of care plan training. At the time of this inspection, the deputy manager had commenced the Registered Managers’ Award and the manager of one of the houses had obtained NVQ level 4 qualifications. We had previously discussed the need for the house managers to be offered management training, taking into account that they manage 30-bedded units. We were informed that the house managers would now be able to access a management course named ‘Journey To Excellence’. Other training provided included mandatory training such as moving and handling, basic food hygiene and infection control, induction for new staff and dementia care. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 23 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): 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. The service demonstrated effective measures to promote the welfare and safety of residents, although the regularity of staff supervision needs to be improved upon. EVIDENCE: The registered manager is a registered general nurse and had successfully completed the Registered Managers Award in June 2008, prior to this inspection visit. Although some positive changes were noted at the random Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 24 inspection in February 2008, this inspection has demonstrated the service’s improved capacity to satisfactorily meet many of the key National Minimum Standards and has also indicated the potential for further achievements. The pharmacist inspection in February 2008 and subsequent monitoring visit highlighted the need for specific and vital improvements that have now been achieved, although other medication issues need to be addressed. As previously stated within this report, the views of residents (and their representatives) were sought through residents and relatives meetings. The service provider conducted annual surveys to identify how to improve the service in accordance to the views of the residents and their supporters. We looked at four randomly selected financial records for residents; no issues of concern were identified. We checked the supervision records on one of the four houses; it was noted that the regularity of the supervision had slipped. One file did not evidence any supervision since August 2007 and another file did not demonstrate that supervision had occurred this year. It was possible that notes were not properly filed. The following health and safety records were checked and found to be satisfactory; electrical installations, portable electrical appliances testing, gas safety certificate, maintenance of the fire alarms and the emergency lighting system, water temperatures and wheelchair maintenance. Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 25 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18 (2) Requirement The Registered Manager must ensure that supervision identifies issues that staff needs additional support and training for. Supervision must be provided at least six times per year. This is a repeated requirement. The Registered Manager must ensure that medication administration records are accurately maintained. Timescale for action 31/10/08 2. OP9 13(2) 31/08/08 Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 27 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 OP9 OP9 Good Practice Recommendations The service should monitor the temperature of medicines storage and if necessary, take temperature-limiting measures. The service should improve its medicines policies and procedures with respect to guidance on the administration of medicines requiring handling precautions, and also improve the reference system so that documents are easily accessible. The service should record the date of first use of medicines when expiry is limited by the period of usage. 3. OP9 Mornington Hall DS0000007363.V364527.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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