Inspection on 16/02/07 for Mornington Road

This inspection was carried out on 16th February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mornington Road 28/09/07

Mornington Road 23/02/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Mornington Road 100 Mornington Road Leytonstone London E11 3DX Lead Inspector Yemi Adegbite Unannounced Inspection 16th February 2007 10:20 Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 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 Road DS0000065856.V311989.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 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. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mornington Road Address 100 Mornington Road Leytonstone London E11 3DX 020 8518 7515 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) Outlook Care Mr John Barry Gleaves Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate 1 service user over the age of 65 with a learning disability 23rd February 2006 Date of last inspection Brief Description of the Service: 100 Mornington Road is a Victorian style building accommodating adults with learning difficulties. The house comprises 6 single bedrooms, a bathroom, two shower rooms and 3 toilets. There is an open plan kitchen to the dining area, a separate laundry room and a lounge. The home aims to provided care and support in daily activities and in accessing the community. At the time of the inspection, there were 5 service users occupying the home. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over the course of a day as part of the regulatory process and was conducted with the full assistance of the deputy manager and a support staff. The inspector was unable to obtain the view of the service users due to their level of disability. The main focus of this inspection was to review progress made with requirements made at the previous inspection and to inspect key National Minimum Standards. There was one service user at home; three service users were out and about in the community with one service user being on weekend leave. The home has one service user vacancy. Staff were very familiar with the needs of the service users and were able to meet these in accordance with the NMS. The staffing level was sufficient to meet the needs of the service users and the atmosphere of the home was relaxed and homely. A number of requirements were made at previous inspections two of which have not been met and have been restated in this report with a new timescale for compliance. Unmet requirements impact on the welfare and safety of service users and the Commission for Social Care Inspection will consider enforcement action for continued non-compliance with issued requirements. The inspector would like to thank the service user and staff for their assistance with this inspection. What the service does well: Detailed individualised person-centred care plans are in place and service users are involved in the development of these. Service users are assisted to maintain and further develop life skills and to take part in activities, which are meaningful to them. They are also assisted and supported to maintain contacts with their family and friends. Staff receive appropriate training and benefit from regular supervision. The house is in good decorative condition. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 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 Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There has been no admission since the last inspection so standards 2, 3 and 4 were not tested. The home have all the relevant information ensuring that prospective service users can make an informed choice about where to live. EVIDENCE: All service users have lived at the home for many years. Although there has been no admission since the last inspection, the deputy manager was able to discuss how the admission process would be managed for a prospective service user. The home currently has one vacancy. Most of the above standards were tested and met during the last inspection apart from standard two. The deputy manager did however specify that an assessment process would be undertaken with any prospective service user ensuring that their aspirations and needs are fully assessed and outlined in their care plan. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 9 A Statement of Purpose and Service User Guide are available for prospective service users and their relative. These provide sufficient information to allow an informed choice. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to make decisions and are given support and assistance as required. Risk assessments need to be updated to reflect the current needs of the service user and in order to protect both the service user and others. Additionally they require information such as the dates of reviews, to evidence that they remain appropriate. EVIDENCE: At previous inspections the homes could not demonstrate that all service users needs were fully assessed. The inspector was pleased to note that the service users files seen were observed to have assessments in place and this is an improvement since the last inspection. This helps to ensure that care plans can be drawn up that meet the needs of the service users. However to fully meet Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 11 the above standards, it is required that all identifiable risks are appropriately assessed and signed by the service users to indicate their involvement. Each service user has a person-centred care plan which gives details of how they need/like to be supported and were partly written in a pictorial format for easy understanding. Areas such as challenging behaviour, emotional/physical health needs and daily living skills had been assessed and reflected on the care plans. A key worker scheme is in place at the home to help ensure continuity of care. Record of key work sessions was seen on the individual care plan. Service users are asked to make decisions about their every day lives and are supported to maximise their independence for example choice of daily clothing, activities and menu are undertaken by service users. Staff described how they encourage service users to make decisions within their capabilities. Staff spoke about how they knew when a service user who has limited verbal communication is expressing their likes or dislikes. Staff have had training from the Speech and Language Therapist and objects of reference are used to aid communication with non-verbal service users. This was evidenced on pictorial records such as care plans, and menu. General and individual risk assessments were in place in the files seen however it was disappointing to note that some of these assessments had not been reviewed as specified. For example one service user whose mobility has deteriorated had a risk assessment completed on the 10/03/06 however there was not evidence to verify that this had been reviewed as required. Given the frailty of the service user and in order to ensure that their safety and well being are met, it is required that all identifiable risks are appropriately assessed every six months or as and when required. Additionally they require information such as the dates of reviews, to evidence that they remain appropriate. The inspector was satisfied that the home organise monthly meetings for service users to participate in the running of the home. This allows service users to raise issues and discuss their likes and dislikes. Recent minutes seen evidenced that matters such as activities, maintenance and menu planning have been discussed. The inspector noted that some outdated service user information was being stored in a second individual service user file. For example the inspector saw a risk assessment in regards to an “epileptic seizure” which was last reviewed on the 20/08/05, the deputy manager stating that this risk no longer applies to the service user. The inspector is of the opinion that it would be more appropriate to archive all old material not relating to the service user in order to ensure safe delivery of care. A recommendation was made for ensuring that service users files are well maintained. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 12 Due to the complex needs of service users they would not have any understanding of standard 10. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15, &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a very good environment for them to develop their social skills. Service users are able to take part in age, peer and culturally appropriate activities and are offered a healthy diet. The home demonstrated an active approach to promoting service users independence. Service users are supported to keep in contact with their relatives and them are welcomed at the home. EVIDENCE: On the day of the inspection two of the service users were out attending their daily activities, one was at home and another was on a home visit. The fifth service user was admitted into hospital. Service users undertake various Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 14 activities including attending day centres, Redbridge College and voluntary employment. A daily activity sheet was also available detailing activity such as drumming session, luncheon club, art classes and Mencap mobile library calls regularly. All of the service users have freedom passed to enable easy access to the local community. One service user is offered four hours extra support funded by Mencap. This service user was accompanied by his support worker accessing the community on the day of the inspection. Through observation and discussion with the acting manager, it was evident that the daily routines and house rules promote independence and individual choice for the service users. The inspector observed staff interacting with the service user throughout the inspection in a positive and appropriate manner. Staff were aware of when service users want to be alone and respect their choice and privacy. The minutes of the service users meetings evidence that service users are consulted and are offered choice in regards to weekly menu. The home does not employ a cook but it was reflected on the menus that varied and wholesome meals, prepared by care support workers, are being provided to the service users. The home has in place a pictorial menu and service users are supported to prepare light snacks depending on their ability. The kitchens were viewed and found to be clean and tidy at the time of the inspection. Fresh produce was seen in fridges and food opened had dates of opening written on it. Fridge and freezer temperatures had been taken and were within an appropriate range. Those service users who have family or friends are encouraged to maintain contact with them. Service users are able to visit family or see them in their home for example; a service user was on home visit on the day of the inspection. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported in a respectful way and personal care is offered in private. Service users health needs are recorded and addressed by relevant health professionals to ensure service users maintain positive health. There continue to be shortfalls in medication systems, which clearly puts service users at risk. Close monitoring and training must be introduced in order to reduce medication errors and to safeguard service users. EVIDENCE: Service users require a range of support and assistance with their personal care and this is offered in private. The home aims to meet individual service users needs, and time for getting up, going to bed, meals and other activities are therefore flexible and tailored to the service users individual needs. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 16 The staff member spoken to by the inspector demonstrated a good understanding and awareness of how to promote service users dignity and respect whilst providing personal care. The health needs of the service users were documented on care plans and where necessary, guidelines were in place. Service user’s weight had been taken, although it was noted that it had not been recorded for one service user for several months. Discussions took place with the deputy manager regarding this lack of evidence and a recommendation was made for this to be addressed. Service users have the opportunity to see a variety of health professionals such as Dentists, Opticians, GP, District Nurse and Chiropodists. Staff support and accompany service users to all appointments. Policies and procedures were available for guidance on the administration of medication. However it was disappointing to note that after several requirements issued during previous inspection, there continue to be shortfalls in medication systems. There were concerns as one medication “calcium carbonate” was out by five tablets. Staff had audited the medication book which reflected that “alfacalcidol capsule” available was 45 tablets however this medication was out by one. The inspector also noted that 30 extra capsules of “alfacalcidol” were accounted for. Additionally part of the MAR sheet was not legible and the medication return form had not be appropriately completed. This is an outstanding requirement and must now be addressed as a matter of urgency. Unmet requirements impact on the welfare and safety of service users and the Commission for Social Care Inspection will consider the use of enforcement action against the home for continued non-compliance with issued requirements. There was no evidence to verify that an appropriate method was in place for the receipt and disposal of medication into the home. The responsible person must ensure that the standard of record keeping is properly maintained, legible and current, providing a complete audit trail of medication. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are listened to and acted on, the homes policies and procedures and staff training protects them from abuse, neglect and self-harm. There is a complaints procedure. However some service users might not be able to make a complaint without support due to the degree of their disability Staff are aware of issues of abuse and work to protect service users from abuse. EVIDENCE: There is a complaints procedure that would be followed in the event of any complaints being made. The home have a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff have attended a course on protecting service users from abuse and are aware of their responsibility to residents. Assessment of the complaint log evidenced that there have been no complaint made since the last inspection. The staff member spoken to during the inspection was very clear that any complaints or concerns by either service users or staff would be dealt with appropriately. They were also was aware of the policies and procedures for the dealing with abuse. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 18 No visitors were in the home during the inspection so the inspector was not able to fully test this standard, as communication with service users was difficult. Staff stated that because of their knowledge of the service users needs, they are able to determine when a service user is unhappy through observation and behaviour changes. This was evident during the course of the inspection as it was observed that staff on duty had great knowledge and understanding in dealing with a service who was quite frail and unable to communicate verbally. Due to their level of disabilities, most of the service users living at the home requires help with their finances as they do not have the capacity to understand the concept of spending or saving money. One service user partly manages his own finance with assistance from the home. Records are kept of financial transactions. Daily checks are made to ensure that these are correct. Service users finances checked at the time of the inspection were correct and appropriate receipts were on file. There are safeguards in place where large expenditures of personal money is being spent on behalf of a service user, and where they are unable to fully understand or contribute to the decision-making process for example, the home is in the process of assisting a service user with the process of purchasing a wheel chair. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a clean home that is suitable for their needs. There are enough facilities in place to meet their needs. EVIDENCE: The home is situated in a quiet residential area of Waltham Forest and is within easy access of transport links and the local community. The home is within walking distance of some local amenities. The inspector was satisfied that the premises is suitable for the stated purpose, and it is accessible to service users. At the time of the inspection, the home was found to be in a good general state of repair. The décor and furnishings were homely. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 20 The communal space consists of a lounge, kitchen/diner and a garden. These areas are clean and satisfactorily maintained and decorated. Each service user has a single bedroom but these were not seen during this visit. The deputy manager stated that due to the nature of their disabilities, service users do not lock their bedrooms however this would be facilitated when the needs arise. There is a shower room and two bedrooms on the ground floor and the remainder of the bedrooms, more bathing facilities and the staff office are on the first and second floor. It was the view of the inspector that there are adequate baths, showers and toilets facilities, which meet the needs of the service users. At the time of the inspection the premises was kept clean, hygienic and free from offensive odours. It was positive to note that a requirement issued in the last inspection report has been met as the home now has appropriate measures in place for the safe disposal of clinical waste. Laundry facilities were kept clean and in good working order. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members are committed and competent to meet the needs of the service users. The team is effective and works well together in the interests of the service users. Staff members receive regular one to one support and supervision to enable them to work to support service users in their every day life. Standard 34 could not be tested due to the absence of the registered manager. However the standard was assessed as being met at the previous inspection. EVIDENCE: In addition to a manager, the home employs a deputy and five support staff. There are usually two members of staff on duty per shift with one member of staff covering the waking night duties. The rota was seen and accurately reflected the members of staff on duty. It was the view of the inspector that Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 22 staffing level on the day on the inspection was adequate to meet the needs of the service users. Staff were observed throughout the inspection and were seen to interact in a supportive way to the service user present during the inspection. Staff spoken to showed a good knowledge of the service users and their needs. Although the manager was not at the home during the course of the inspection, the staff on duty were going about their duties in a professional manner and the home had a good atmosphere and was well organised. Staff members receive mandatory training and additional relevant training on an going basis. The inspector viewed training certificates held on file. Training that they had undertaken this year by staff was: manual handling, food hygiene, basic first aid, and health & safety training, helping to manage dementia and aspect of ageing. These trainings are particularly relevant to a service user whose health needs is deteriorating due to recent diagnosis. The majority of the staff team have either obtained an NVQ or are in the process of studying for this qualification. A member of staff spoken to said that the home is very good and offers the service users exceptional care. Staff receive regular one to one supervision and the staff spoken to felt supervision sessions were useful and offered them the opportunity to seek advice or guidance where necessary. There are regular monthly team meetings to enable staff to meet and discuss any issues, or share information as a whole team. Standards 34 could not be tested at this inspection due to the absence of the registered manager and the safe security of staff personal details. However this standard was tested at the previous inspection and assessed as been met. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to review the quality of care offered in the home. However for this to be fully met the views of relatives and stakeholders must be sought with there view available for interested parties Policies and procedures are in place however it is required that these are implemented in the overall running of the home in order to ensure that service users well being are fully met. EVIDENCE: The Registered Manager has been in post since September 2005 and has completed the NVQ level 4 qualification. They have the necessary skills and expertise to manage the day-to-day running of the home. Staff asked, stated Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 24 the registered manager was approachable and could be consulted if staff need advice. The homes deputy manager has also completed the NVQ level 4 qualification and has relevant caring experience. It was positively noted that most of the requirements issued at the previous inspection report had been met. However it was with disappointment and of great concern to noted that the home continues to encounter shortfall when dealing with service users medication. Additionally it is required that all service users health needs are fully assessed and kept under review. There are systems in place through various methods to review the quality of care offered in the home for example at service users meeting, staff meetings and review of care plans. However for this to be fully met, the inspector discussed with the deputy manager evidence that the home needs to further develop its quality assurance process to include feedback from service users, their families and other stakeholders. The results of this feedback should be collated and made available to interested parties. The home’s written policies and procedures are available to staff at all times. However as stated in standards 6, 9 and 20, it is required that policies are implemented in the day to day running of the home to ensure that appropriate procedures are taken at all times. Monthly Regulation 26 visits take place and evidence of these were seen and available for inspection. Servicing records were viewed at random. The portable appliance testing and gas safety record was up to date. Fire call points are checked on a regular basis and the fire alarm has been checked. Fire drills/practices are recorded and provide all staff and service users with the opportunity to respond appropriately. Mornington Road DS0000065856.V311989.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 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 Standard No Score 1 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X X 2 X Mornington Road DS0000065856.V311989.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 YA9 Regulation 13.4 Requirement Timescale for action 30/04/07 2. YA19 13.1 3. YA20 13.2 The registered manager must ensure that all unnecessary risks to health and safety of service users are identified and so far as possible eliminated. Additionally they require information such as dates of reviews to evidence that they remain appropriate (Timescale 31/07/05 not met) The registered manager 30/04/07 must ensure that service users health needs are accurately monitored The registered manager 28/06/07 must ensure that medications administered are recorded accurately. (Timescale 31/07/05 and 30/04/06 not met) The Registered Person 28/06/07 must ensure that the quality monitoring system is conducted with the involvement of relatives and stakeholders. This must be collated and made DS0000065856.V311989.R01.S.doc Version 5.2 Page 27 4. YA39 24(2) Mornington Road available for inspection. 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 YA6 YA19 YA19 Good Practice Recommendations Guidelines should be dated to ensure documents are up to date and reviewed on a regular basis. In order to ensure the safe delivery of care, it is recommended that old documents not relating to the service users present needs are archived. Service users weight should be clearly recorded on a regular basis. Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mornington Road DS0000065856.V311989.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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