Inspection on 30/05/06 for Mount Denys

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 but made no statutory requirements on the home.

Other inspections for this house

Mount Denys 26/11/07

Mount Denys 10/11/05

Mount Denys 26/04/05

Mount Denys 19/11/04

Mount Denys 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Mount Denys 187 The Ridge Hastings East Sussex TN34 2HE Lead Inspector Judy Gossedge Key Unannounced Inspection 30th May 2006 09:30 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 Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 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. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mount Denys Address 187 The Ridge Hastings East Sussex TN34 2HE 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) 01424 421353 01424 421925 www.eastsussex.gov.uk/socialcare East Sussex County Council Mrs Florence Gertrude Beddall Care Home 31 Category(ies) of Dementia - over 65 years of age (31) registration, with number of places Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The maximum number of service users to be accommodated is thirtyone (31). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. Five (5) places will be available for service users between the age of fifty-five (55) and sixty-four (64). One (1) named service user who has been assessed as requiring nursing care be accommodated. One (1) named service user with mental health issues can be accommodated. 10th November 2005 Date of last inspection Brief Description of the Service: Mount Denys is a purpose built property on two floors, situated on the outskirts of Hastings and approximately two miles from the town centre. Managed by East Sussex County Council (ESCC) it is a specialist service for older people with dementia in Hastings and Rother. Bexhill and Rother and Hastings and St Leonards Primary Care Trusts commission the service, with the care managed by ESCC. Service user accommodation comprises of thirty-one single bedrooms within three units in the home. There are two units of ten beds and one unit of eleven beds, which are used to provide service users with accommodation for either long term care, short stay, respite care and periods of assessment. There is only one en-suite facility, but there are sufficient toilet and assisted bathing facilities on each of the units. Each unit has a dining and lounge area for service users to use. Additionally there is a large lounge area on the ground floor. Level access is facilitated in the home with the provision of a passenger lift. A pleasant garden is at the rear of the home. Fees charged are in accordance with ESCC policy and procedures and at the time of the inspection the charges are £94.45-£501.06. The level of fees charged will depend on the outcome of a financial assessment. Additional charges are made for hairdressing, newspapers and toiletries. The Statement of Purpose, Service Users Guide and a copy of the last inspection report are available to read in the reception area of the home. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over eight hours on 30 May 2006. Prior to the inspection a pre-inspection questionnaire was sent to the home to be completed with information required as part of the inspection process. This was returned and information detailed is quoted in this report. A tour of the home took place including communal areas and a sample of service users bedrooms. Rotas and care records were also inspected. There were twentynine service users resident and for four service users the care that they received was reviewed as part of the inspection process. Due to communication difficulties it was not possible to speak to all the service users individually, but seven service users were spoken with during the day and the opportunity was also taken to observe the interaction between staff and service users in the communal areas. Ten service user surveys had been forwarded to the home prior to the inspection and six completed surveys were returned, all completed by service users relatives. The Manager, three senior care officers, five care workers two of whom also work as relief night care officers, two housekeeping staff who both also work as relief care assistants, two catering staff and the administrative assistant were all spoken with. Nine staff questionnaires were sent out prior to the inspection and five completed questionnaires were returned. There were no visitors visiting on the day, but three relatives who are regular visitors to the home were subsequently contacted and spoken with on the telephone. Two general practitioners were sent comment cards and one completed card was returned. What the service does well: What has improved since the last inspection? Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 6 The Statement of Purpose, Service Users Guide and a copy of the last inspection report are available to read in the entrance to the home. Service users are protected with a contract detailing the terms and conditions. Service users are protected with the exposed hot pipes in the bathrooms being guarded. Confirmation has been received that the areas highlighted by the ESCC Fire Officer have been addressed. 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. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 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 Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 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): 1,2,3 and 6 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The admissions process is good as staff are provided with adequate information prior to admission to ensure each new service users care needs can be met in the home, or prepare for any specific care needs prior to admission. But where service users are receiving respite care an update of the service users current care needs should be recorded. EVIDENCE: A copy of the Statement of Purpose, the Service Users Guide and the last inspection report are in the homes new reception area for people to read. Five service users surveys stated they had received enough information about Mount Denys prior to moving into the home. ESCC has a written contract to be used between the home and the service user, detailing the terms and conditions. Three service users surveys stated they had received a contract. Four files for new service users were viewed and Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 9 all had a contract in place. The bedroom to be occupied is not always recorded and should be. Prior to admission to the home service users have an assessment completed, primarily by staff from the Community Mental Health Team, or staff from one of ESCC Adult Social Care Department’s Assessment Teams. A copy of the assessment is then forwarded to the home. For the three new service users at Mount Denys, the pre-admission information had been received. Staff confirmed that they also visit a new service user prior to a planned admission to gain information to help them provide the required care. Where service users are being provided with regular respite care the assessment should be subject to regular review. Where service users are admitted between reviews staff stated verbal confirmation of the current situation is sought prior to the service user being admitted for the next period of respite care. This needs to be evidenced and recorded for staff to reference. Intermediate care is not provided in the home. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 10 Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 the available evidence including a visit to this service. Service users are protected by an individual plan of care where their personal and health care needs are identified, which informs staff of the care which needs to be provided. But the information recorded should continue to be developed and it should be ensured that the care plan is started when a service user is admitted in to the home. EVIDENCE: Individual service user documentation was viewed and was varied with a new format to record service users care needs in the process of being introduced. Eight service users files were viewed. The content of the individual care plans read demonstrated that the detail included on the care plans continues to be improved, but should continue to be developed to ensure that all service users care needs are recorded and give staff guidance on all areas of care as required. Recording was in place to demonstrate that care plans had been reviewed. Supporting risk assessments were also recorded, but not all service users had had a falls risk assessment completed. For one service user who had been admitted the previous day a care plan had not been started and Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 12 there was no falls risk assessment, although the pre-admission assessment detailed a risk of falls. Service users religion was not always recorded and where possible this information should be sought to ensure where a death occurs appropriate actions are taken in line with service users or relative’s wishes. Feedback from the visiting healthcare professional was that they were satisfied with the overall care provided, that the home worked in partnership with them and commented, ‘ Excellent care home. Medication policies and procedures are in place and the administration of medication was observed at lunchtime and at teatime. The storage and a sample of the recording of the administration of medication were also viewed. A number of omissions in the recording of administration of medication were seen. This was discussed with the Manager during the inspection and an Immediate Requirement Form was left for this issue to be addressed. Staff confirmed, but the records were not available to view, that a pharmacist regularly visits. All the service user surveys completed indicated that service users felt that their medical care needs were met in the home. The care provided was observed being delivered in a way to ensure service users dignity and respect was maintained. The feedback received from the service user surveys and relatives spoken with was that they were pleased with the overall care provided in the home. Comments included, ‘I am very pleased with the care my relative is receiving at Mount Denys. The staff are always cheerful and dedicated’, ‘We were very grateful to the home for the good care and support they gave us, we would use the home again. The staff were very kind and caring’ and Staff are exceptionally good, terribly flexible, good natured and fun to be with. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are enabled where possible to exercise choice and control over their lives whist resident in the home, with opportunities to participate in social and recreational activities and with a varied diet provided which offers choices at every meal. EVIDENCE: On the day of the inspection the weather was cold and none of service users took the opportunity to wander in the new garden area. Activities are organised in the new downstairs lounge. On the morning of the inspection the staff member nominated to run activities was called away to be an escort for a service user leaving the home and no activities were organised. During the afternoon there was a game of bingo and service users from all units were seen to be participating in this activity. Two service users spoke of making cakes the previous day. The six service users surveys responses were varied and stated activities were always, sometimes, usually or never provided. Two relatives spoken with were able to comment on activities provided which they had observed during their visits to the home. A sample of the recording of activities arranged was viewed and with observations on the day, staff spoken with and service users and relatives comments evidenced that activities are Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 14 being organised for service users to participate in. Additionally staff stated there are now more opportunities for service user’s to go out on trips if they wish. Not all service users individual care plans detailed their preferred social activities. This was shared with the Manager who confirmed she was aware of this and stated that this is an area staff are working on to improve. The care and support provided was observed to enable service users where possible to exercise choice whilst at Mount Denys. The eight service user files viewed and the three relatives spoken with confirmed this. The three relatives spoken with confirmed that there is flexible visiting, that they are always welcomed and can visit with their relative in private if they wish. The cook and agency kitchen assistant working in the kitchen on the day were spoken with and stated they both hold a basic food hygiene certificate. The cook also confirmed attendance on a range of training opportunities. There is a four-week rotating menu in place detailing a choice at all meals and some service users were seen to be choosing their meal from the choice available on the day. Frozen meals are used to provide the main meal at lunchtime in the home. Special diets are catered for. Lunch was vienna steaks or cauliflower cheese with creamed potatoes, savoy cabbage and mixed vegetables, followed by apple or plum crumble, ice-cream or yoghurts. The dessert was not as detailed on the menu, which the cook stated did not often occur, but was due to the change from the winter to summer menu and the need to finish up stocks held in the home. It was not always possible to evidence a varied and adequate diet for all service users from the records kept of food consumed individually by each service user. This was raised with the Manager during the inspection, who subsequently confirmed that recorded had been split between two sets of recording in place and this would be addressed. Service users were observed eating their lunch on one of the flats and there was a relaxed atmosphere during the meal. Fresh fruit is available on the units. Feedback from service users about the food was varied; two stated they would have liked to have more gravy with their meal. The six service users surveys stated they always or usually liked the food provided. The relatives commented, I am extremely pleased as my relative is the slowest eater and is never hurried or nagged. I feel he enjoys his food more. Another commented that their relative now ate a more varied diet than at home and had been observed to enjoy their food. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The outcome in this area is good. This judgement has been made using the available evidence including a visit to this service. Systems are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. EVIDENCE: ESCC has a detailed compliments and complaints policy and procedure in place. Any complaints received are monitored through the line management arrangements in place within the organisation. Three complaints have been received at the home since the last inspection. The CSCI has not received any concerns since the last inspection. The six service users surveys stated they always know how to make a complaint. The three relatives spoken with felt it was an environment where they would feel able to raise any issues and knew the person they should speak to. None had made any complaints, but for one where their relative had they stated they felt their relative had been listened to and had been happy with the outcome of the investigation. There are detailed policies and procedures in place in relation to the protection of vulnerable adults and a whistle blowing policy. All five of the staff questionnaires confirmed an awareness of adult protection procedures. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 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): 19,25 and 26 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The standard of the environment continues to be improved, but there are still areas in the home, which do not provide service users with an attractive and homely place to live. EVIDENCE: A tour of the building was made. Work has been completed to refurbish the large downstairs lounge, all corridor areas have been redecorated and new carpeting fitted. One service user stated Its marvellous. Staff also spoke very well of working in the improved environment. The Manager stated that the main kitchen is due for refurbishment during July 2006; a new emergency call system is to be fitted in the home and new baths provided by April 2007. The standard of décor, carpeting and furnishings continues to be poor in some bedrooms and in the bathrooms and toilets. An action plan with timescales to address this issue has been requested. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 17 There are thirty-one single bedrooms of which twenty do not meet the minimum space requirements. Service users are unable to control the temperature in their own bedrooms. The CSCI has been previously been informed that the heating system in the home does not allow for this facility to be provided. Several of the bedrooms were seen and reflected a range of individual styles and interests. All bedrooms have a call bell system linked to an alarm, which is turned off at the main control panel rather than in the service users bedroom. Only one bedroom has en-suite facilities, but there are adequate toilets and assisted bathing facilities on each of the units in the home. Bathrooms and toilets are not homely and the décor is poor. Eleven hot water outlets used by service users were checked on the day and all were close to the recommended safe temperature of 43° C. There were also records of regular checks of the hot water temperature carried out in the home. The Water Supply Regulations 1999 are met and a risk assessment in relation to Legionella is in place. There is a dining and lounge space on each of the flats. There is a very pleasant garden at the rear of the home, which has recently been subject to major work to improve this facility. One service user comment card stated, It would be nice to see more use made of the garden. More use of best practice techniques for living space design for dementia patients, for example the use of colour, unusual images, keeping things in line of sight as reminders. The home was clean and free from offensive odours. All of the feedback received confirmed the home was kept fresh and clean. The two housekeeping staff spoken with stated they had attended training in the control of hazardous substances and were aware of infection control policies and procedures within the home. They confirmed there was good availability of disposable gloves and aprons. Laundry facilities are provided in the home. Recordings of the regular fire checks carried out in the home were seen and were adequate. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 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): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing was in place on the day but a robust recruitment procedure needs to be demonstrated to be in place to ensure service users are in safe hands at all times. EVIDENCE: A copy of the staff rota was provided with the pre-inspection questionnaire. Staffing on the day was adequate to meet the number and care needs of the service users resident. Although it did not enable an activity to be organised during the morning of the inspection and this needs to be monitored to ensure service users social care needs continue to be met. Ancillary staff working in the home cover the catering and domestic tasks, with laundry tasks being undertaken by care staff on each of the units. The relatives spoken with stated that they felt there were adequate numbers of staff on duty during their visits. All six of the service users surveys stated they felt that they received the care and support that they needed, that staff listened and acted upon what was said to them and that staff were always available when they were needed. Staff feedback from the completed questionnaires received were, ‘Care is good for service users and their needs are met’, ‘On the whole we are a very close team that can work well together towards providing the highest level of care for our service users’ and ‘Service users are put first and their rights are adhered to’. Further comments received were that staff communication could Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 19 be improved and that staff would welcome more time to provide social activities for the service users. The Inspector received feedback from staff during the inspection, which indicated a good and supportive team. Standard 28 has not been met as fifty percent of the staff have not achieved NVQ level 2 or equivalent in care by April 2005. The pre-inspection questionnaire detailed nine care staff hold an NVQ level 2 in care. This equates to thirty percent of the homes care staff and four further care staff are currently working towards this qualification. All recruitment of ESCC staff is co-ordinated by the Personnel Section at ESCC’s head office. Evidence of the recruitment process followed for new staff is now held at the home. Five staff files were viewed of which two did not have photographic evidence in place as required and one only had one written reference in place. The Manager provided a list of all the staffs CRB checks and was able to confirm all staff had a CRB check in place. There has not been any recruitment of new staff since the last inspection, so it was not possible to evidence if induction training has been provided. But two staff files viewed did demonstrate an induction had been completed. The Manager stated and detailed in the pre-inspection questionnaire that it is ensured that all new staff are supported to complete the required induction programme. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 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): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the home is good with effective systems to protect service users being put in place, but these need to be maintained. EVIDENCE: An experienced Manager who has worked for ESCC for a number of years and has previously been a Registered Manager at another ESCC care home is managing Mount Denys. She has participated in a range of training opportunities, has completed the Registered Managers Award and is currently undertaking NVQ Level 4 in care. There are clear lines of line management and accountability within the organisation. ESCC has a quality assurance plan, which is starting to be fully implemented in the home. There are opportunities for service users and carers to put forward Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 21 their views about the home and the care that they receive through service users forums. Service users/representatives are also asked to complete a questionnaire at the end of a period of care. ESCC had confirmed that feedback from the quality assurance process undertaken at Mount Denys was being collated and would be available to read in April 2006, but this had not been completed. ESCC have been asked to confirm completion. A formal process to gain feedback from other stakeholders has been developed. Regular quality assurance visits by a representative of ESCC are completed and recorded to meet the requirement under Regulation 26 and are regularly sent to the CSCI. Where money is held in safe keeping for some service users a sample of the financial records to support this activity was viewed and was adequate. The majority of the staff questionnaires, staff spoken with and records viewed confirmed that staff supervision occurs on a regular and ongoing basis. One comment on a staff questionnaire received was that group supervision had not occurred for a while. Staff stated they had attended a range of training and training updates. They all spoke of good access to training opportunities for personal development and of training records were being updated. Staff training records had not been completed, nor were available to view, so it was not possible to evidence that all staff had received the required moving and handling updates, first aid, basic food hygiene and fire training. Accident records were viewed and were collated, so that any trends in incidents or accidents occurring in the home can be highlighted. A fire risk assessment was viewed but had not have been updated since April 2005. A detailed check of the environment and fire precautions had been carried out to meet the timescales as detailed in ESCC’s policies and procedures. ESCC had confirmed the fire training to be undertaken at Mount Denys to meet requirements. This was not evidenced to be in place or that staff were aware of ESCC’s policy and procedure to meet these requirements. ESCC have been asked to provide an action plan to address this issue. The organisation has a system in place to evidence that the maintenance of equipment and services has been carried out. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 3 3 2 Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 23 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 OP3 Regulation 14 (1) (B) Requirement Where service users are being provided with regular respite care the assessment should be subject to regular review. Where service users are admitted between reviews the updates of individual service users care needs should be evidenced and recorded for staff to reference. That a falls risk assessment is completed for all service users on admission. The recording of administration of medication is maintained. This issue is outstanding since 30.06.05 and 10.11.05. That an action plan with timescales is provided to identify work to be completed on the bathrooms and bedrooms in the home is provided. That there is photographic evidence of staff members held at the home. That confirmation is provided that the member of staff with only one reference to view has Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 24 Timescale for action 31/07/06 2. 3. OP7 OP9 13 (4) (c) 13 (2) 31/07/06 30/05/06 4. OP19 23 (2) (ab) 31/07/06 5. OP29 19 (1) (a) (b) 31/07/06 6. OP33 24 (1) (2) (3) 18 (c) (i) 7. OP38 8. OP38 23 (4) (d) two written references in place. The outcome of the service user quality assurance is made available to read. Feedback sought from other stakeholders. That confirmation is provided that staff have received the required updates in moving and handling, basic food hygiene, infection control, and first aid. This issue is outstanding since 30.06.05 and 28.02.06. That an action plan with timescales to identify how ESCC’s policy and procedure on fire training to be provided to staff will be actioned in the home. 31/08/06 31/07/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations That service users religion is recorded. Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Mount Denys DS0000041274.V291065.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!