Inspection on 19/02/08 for Mount Lodge

This inspection was carried out on 19th February 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mount Lodge 16/03/07

Mount Lodge 06/09/05

Mount Lodge 22/04/05

Mount Lodge 26/08/04

Mount Lodge 17/05/04

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

CARE HOME ADULTS 18-65 Mount Lodge 5 Upper Avenue Eastbourne East Sussex BN21 3UY Lead Inspector Melanie Freeman Unannounced Inspection 19th February 2008 09:30 Mount Lodge DS0000021169.V357931.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 Mount Lodge DS0000021169.V357931.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. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Lodge Address 5 Upper Avenue Eastbourne East Sussex BN21 3UY 01323 411312 01323 411312 mountlodge@cht.org.uk www.cht.org.uk Community Housing and Therapy 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) Position Vacant Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is sixteen (16). That service users are aged between eighteen (18) and sixty-five (65) years on admission. That only service users with a mental disorder, excluding learning disability or dementia, to be admitted. 16th March 2007 Date of last inspection Brief Description of the Service: Mount Lodge, first registered in 1993, is a therapeutic community run by Community Housing and Therapy, (CHT), for 16 adults, between the ages of 18 and 65, who are experiencing mental health and emotional difficulties, excluding learning disability or dementia. Many service users (clients) have ‘dual diagnosis’ and in addition to their psychiatric condition may also have problems with substance misuse. The premises comprise of a large, three storey detached house, with an extensive garden to the rear and parking space at the front of the building. Service user accommodation comprises of single rooms, each fitted with a washbasin. Communal areas include two large lounges, a separate dining room, an additional quiet lounge and a kitchen and laundry room. Sufficient toilets and bathrooms are provided throughout. The home is situated in a residential area of Eastbourne, a short walk from the town centre amenities, including shops and the main line railway station. A local bus service passes near by. Client’s involvement is a significant aspect of the organisation’s approach to community care. Regular group discussion meetings form the basis for much of the structured work within the community. Independence and self-awareness is promoted within the community and clients are encouraged to contribute to the day- to- day running of the home, including cleaning and planning and preparing meals. Weekly fees are negotiated on an individual basis depending on the needs of clients but would normally range between £750.00 - £850.00 as at 19/02/08, with clients paying for specific toiletries and any extra leisure activities. Mount Lodge DS0000021169.V357931.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 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Mount Lodge will be referred to as ‘clients’. This was a key inspection that included an unannounced visit to the home and follow up contact with two visiting health care professional. The allocated inspector spent approximately five hours in the home and was able to discuss matters with the appointed manager who facilitated the inspection. A tour of the premises was undertaken and records relating to the care of the clients and the management of the home were examined. Two clients were spoken to in private and staff interaction with clients was observed throughout the inspection visit. The required Annual Quality Assurance Assessment (AQAA) was completed and returned prior to the inspection visit and information from this has been used to inform this report. Although surveys were supplied to the home known had been returned at the time that the report was written. What the service does well: A full and comprehensive admission procedure is followed to ensure a suitable placement that is going to be beneficial is achieved. Staff form appropriate relationships with clients that allow for an open and inclusive atmosphere where clients are empowered and given the support that they need to help them move to a more independent lifestyle. Mount lodge is able to provide an environment that facilitates group living in a homely and comfortable environment. Staff training is given a high priority where staff can develop their professional skills as well as ensuring all the necessary mandatory training is completed. Mount Lodge DS0000021169.V357931.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. Mount Lodge DS0000021169.V357931.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 Mount Lodge DS0000021169.V357931.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 and 2 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Perspective clients are given full information about the home and the therapeutic work undertaken with clients, the pre admission assessment process is thorough and is completed by competent staff in consultation with the prospective client who makes a positive choice to move into the home. EVIDENCE: A statement of purpose and service users guide is readily available on request along with the last inspection report. Any prospective client is given a copy of the service users guide and statement of purpose when they are first referred for a placement. An assessment of the admission process included a review of the documentation used in respect of two recent admissions to the home. These demonstrated that the assessment included a full history and current risk assessment provided by the referring care manager who also completes an application for the placement for the home to consider. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 9 Staff complete a full assessment that includes a risk assessment that takes into account if the individual is suitable for a placement and an interview which explores what the prospective client hopes to gain from their stay at Mount Lodge and their commitment to the project. Prospective clients are invited for a series of visits prior to moving in including an overnight stay. Most of these visits are informal and allow for them to join in aspects of the therapeutic programme, meet staff and other clients. These meetings allow for existing clients and staffs views to be taken into account as part of the admission process. Clients spoken to were positive about the admission process and a prospective client was visiting the home for an assessment interview on the day of this visit. Mount Lodge DS0000021169.V357931.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 and 9 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Clients assessed needs are reflected in an individual plan of care that encourages clients involvement in decision making. Any risks are assessed and responded to promoting an independent lifestyle. EVIDENCE: The care documentation for two clients were reviewed as part of the inspection process. Each client had an individual care plan that takes into account mental, emotional, social and physical needs and reflects how the home can help them in meeting these needs. These plans are discussed with the clients and are signed by them to record their agreement. There was evidence that the plans of care are reviewed and updated regularly to include changing needs. Individual risk assessments are also completed and these usually include a plan of action to reduce the risk and promote the therapeutic programme. One risk assessment reviewed did not indicate the plan of action fully and when this was discussed with the appointed manager she was able to verbalise the Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 11 action plan and confirmed that she would update the documentation accordingly. The care documentation promotes client’s independence and non-reliance on other people. While living at Mount Lodge clients are given a sense of structure and routine in their daily life. Regular community support meetings allow clients to share their views on community living and for them to make choices on how the group lives together in a positive way. A recent example of this is the group decision not to have alcohol in the home. Group decisions are made about what meals are to be prepared in the home and they work together to complete daily routines like cleaning. Clients are able to develop relationships in the home with each other and staff members thereby relearning to socialise, live with others and participate in society. All clients are encouraged to be involved in writing and reviewing their care plans and reviews of their progress. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 12 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, 16 and 17 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Clients are support to become part of the local community and maintain family links and friendships. Although an independent lifestyle is supported clients are expected to participate positively in the communal living programme. Clients and staff work together to provide a wholesome and balanced diet. EVIDENCE: Emotional and social care needs are addressed within the plan of care. The routines and rules at the home are flexible and promote independence and individual choices, subject to the restrictions agreed in the clients care plan. The acting manager confirmed that clients are encouraged to participate in outside activities including day centres and voluntary work opportunities when they are ready to do so once they feel well settled at Mount Lodge. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 13 Clients have the opportunity to join in a weekly leisure group held on a Wednesday that facilitates group leisure activity, which could include a group walk or trip to the cinema. Clients often have boyfriends and girlfriend outside the home and although these relationships are respected clients participation in the homes routines and programmes is known to be important and over reliance on one individual for all support is not encouraged. Other family links are supported and clients are able to visit relatives often staying for a couple of days, or invite them to Mount Lodge if they wish. On a daily basis one client cooks for the rest of the community, and what to eat is agreed on a communal basis. The client will shop for the food and prepare the food with staff support as needed. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 14 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 and 20 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Any personal support offered is tailored to individual need whilst the physical and emotional health needs are met by the community resources. The homes practices in respect of medicines administration and storage do not ensure client safety or comply with legislation. EVIDENCE: Each client is registered with a local General Practitioner and are encouraged to make regular appointments with them and other health professionals. Staff are available to accompany clients to appointments if needed although independence in this area is important. The home has regular contact with the Community Mental Health Team who are available for support and advice. The two health care professionals contacted following the inspection visit were very positive about the level of communication between them and the home. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 15 There are currently no clients self medicating in Mount Lodge, this is due to the fact there was one incident of a member of the community bullying another for medication. As part of the current risk assessment it was thought for a period of time it would be safer for staff to adminsiter all medication that is ordered and checked by the staff on arrival to the home. The plan is to return to self-admisitration in the future following appropriate risk assessments. The last inspection identified that the records relating to medicine admiistration were poor. Although staff have received training on medicines and there has been some improvement to some records, a review of the medicine admisitration charts, storage facilities and homes policies and procedures identifiied a number of shortfalls. The medicine admisitration charts were not complete gaps were noted and it was not clear if clients had recived their medication. Many medicines are prescribed on an as required baisis and the records related to these did not identify clearly or confirm why medicines are taken or not. There needs to be individual guidelines for each client in respect of these medicines so that staff can monitor what medicines are being taken and why so that this can be monitored and responded to. Records should provide clear information to inform the care and support provided to each client. The controlled drugs records were not clear or accurate and did not follow the organisations own policies and procedures. An example of this was the fact that Controlled drugs coming into the home were not always entered into the controlled drugs register. Following the inspection visit the registered manager confirmed that she is arranging for the suppling pharmascist to visit the home to give further advice on the handling of Controlled drugs. It was also noted that a photograph of each client was not retained in the home the appointed manager said that she would adress this matter and ensure suitable photographs are retained. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 16 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 and 23 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The open and inclusive atmosphere enables clients and staff to express any concerns they have and feel they will be listened to. Policies, procedures and practice in the home protect vulnerable adults from abuse. EVIDENCE: Although there is a comprehensive complaints procedure this did not include how complaints would be dealt with when received from people not living in the home. The procedure also needs to record timescale for investigation and responses in accordance with what is required. Staff are in constant contact, at quite a deep level, with all clients, meeting them in therapy and practial groups on a daily basis and once a week for individual therapy. Informal interaction is also happening every day and this allows the sharing of any issues or concerns around complaints or any abusive behaviour inside or outside of the home. The therauputic nature of the home means that things tend to be dealt with in an open manner and staff are aware of any issues. No complaints have been made about the services provided at Mount Lodge to the home or the Commission since the last inspection. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 17 The home has an extensive adult protection procedure although it was noted that this needs to be updated to reflect the new local policies and procedures on Safeguarding Vulnerable Adults and the current registering authority. The appointed manager confirmed that this would be completed. Staff have received training on adult abuse issues and the close contact with clients allows for potential abuse or any suspicion of abuse to be monitored. Daily staff handover meetings, weekly group supervision and other therapeutic groups allow for such matters to be discussed. Individual risk assessments also provide a plan of action to manage any assessed risk. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 18 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 and 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Clients benefit from a homely, comfortable and safe environment that is kept reasonably clean and hygienic. EVIDENCE: Mount Lodge is a large detached house laid out over three floors, which has been adapted to its current use. It retains a large family home feel with light and airy communal areas that does not feel institutional. Each client has a single bedroom that provides basic accommodation that the occupant can personalise. Client’s rooms are clearly seen as their private space and respected as such. There is adequate access to bathrooms and toilets on all floors of the house, although it was noted that not all communal toilets had suitable hand washing facilities to promote good hand washing practice. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 19 There is a secluded rear garden that can be enjoyed in good weather and clients can also complete some gardening as part of the therapeutic programme if they so wish. The communal areas of the home are well used and clients with the help of the staff are responsible for the homes’ cleaning, which is used as part of the therapeutic programme. During the inspection visit the home was found to have a satisfactory standard of cleaning although some carpets were heavily stained and would benefit from regular shampooing. On going redecoration is being progressed and this should include the replacement of any damaged furniture. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 20 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, 34 and 35 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff have a sound understanding of clients needs, and there are sufficient trained staff on duty at all times. The recruitment practice followed protects clients. EVIDENCE: Staffing arrangement provide two therapists working during the day with one providing a sleep over cover in the home from 21.00 to 09.00 in the morning. The appointed manager and deputy manager work on a 09.00 to 17.00 basis Monday to Friday. All the staff working at Mount Lodge are well qualified having completed a Degree in Psychology. New staff typically do a one-year apprenticeship before being promoted to a therapist. Staff receive weekly supervision sessions with the manager or the deputy manager and receive on-going support in respect to their individual allocated clients and all aspects of their work and development. The staff team at Mount Lodge is stable with four of the staff members having worked in the home for a number of years. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 21 Community Housing Therapy are committed to staff training and organises much of the statutory training from head office. Recent training completed included first aid, health and safety, fire training, POVA and safe handling of medication. All members of staff complete a Diploma in Group Psychotherapy for Therapeutic Community Practitioners and are encouraged to complete other training professional studies to develop their skills. Staff are committed to the ethos and therapeutic programme at Mount Lodge and have very good communication skills to promote this. All feedback from all people spoken to was very positive about the staff working in the home with health care professionals saying that the staff are good and the outcomes for clients are positive. The recruitment files pertaining to the three staff were reviewed as part of the inspection process. These confirmed that each staff member completes an application and references are sourced. Following contact with head office it was also confirmed that all staff had a POVA and Criminal Records Bureau checks had been completed. The appointed manager was reminded that she had a responsibility to ensure that all the necessary checks are completed before allowing anyone to work in the home. Whilst each file includes evidence of an individual’s identity a recent photograph was not available and the appointed manager confirmed that she would ensure suitable photographs are filed. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 22 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 and 42 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Clients benefit from a well run home where client’s views are listened to. Systems are in place to protect client’s health, safety and welfare. EVIDENCE: The appointed manager has been in post for a year and confirmed that she was progressing her registration with the Commission for Social Care Inspection. She is also aware that she needs to complete a suitable management qualification and has been looking at courses available. She has worked in the home before and has experience of providing support for individuals with mental health problems. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 23 Since her appointment she has provided clear and strong leadership to the project providing a direction and focus for the therapeutic programme. All feedback received about her was very positive with a clear acknowledgement that her input had greatly improved the service provided at Mount Lodge. Comments included ‘The manager is strong and she is proactive and provides a clear structure to the project’ ‘the manager has done very well and is committed’. There was evidence available to demonstrate that staff at all levels receive a good level of supervision and support and both the appointed manager and deputy have received training on supervision. Although feedback from clients is received on a continuous basis this is not recorded in a formal way that can be audited and used to monitor the quality of the service. The manager also advised that she intends to use questionnaires to obtain feedback from clients, family, friends, advocates or allied health professionals as part of the quality monitoring systems. The home are currently part of a research project being undertaken by Nottingham University that is looking into the effectiveness of the Therapetic Community Approach to working with mental health clients. This will enable to home to see how ell they are meeting the aims and objectives of the project. The AQAA was well completed and demonstrated that the homes management are responsive to the views of clients and staff and proactive in moving the service forward with planned improvements. The home does have systems in place in relation to health and safety and relavant policies and procedures are in place. A fire risk assessment has been completed and the appointed manager said that this will be updated in the near future alon g with the completion of portable appliance checking throughout the home. Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 24 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 4 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 3 X Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement That appropriate procedures are followed and include clear record keeping ensuring controlled drugs are handled in accordance with Misuse of Drugs (safe custody) regulations 1973. Timescale for action 15/03/08 2. YA20 13(2) 3. YA22 4. YA39 That all medicines are handled to ensure residents safety and accurate records are maintained. That each resident has an up to date photograph held on file. 22 (1) That a thorough complaints procedure is established and used to investigate complaints made by clients or anyone acting on their behalf. 24 That further quality assurance (1)(a)(b)(3) systems are developed to take into account clients and their representative’s views. 15/03/08 01/04/08 01/06/08 Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 26 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 YA20 Good Practice Recommendations Clear guidance should be available to staff, on all medicines prescribed on an as required basis, to take into consideration each resident’s needs and choices, in addition to the prescriber’s directions. That communal hand washing areas are provided with suitable hand washing facilities including liquid soap dispensers. That the carpets in the home are professionally cleaned on a regular basis. 2 3 YA30 YA30 Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Mount Lodge DS0000021169.V357931.R01.S.doc Version 5.2 Page 28 - 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. 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