Inspection on 08/02/08 for Mount Olive Residential Care Home

This inspection was carried out on 8th February 2008.

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

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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mount Olive Residential Care Home 31/07/08

Mount Olive Residential Care Home 24/09/07

Mount Olive Residential Care Home 26/02/07

Mount Olive Residential Care Home 18/10/05

Mount Olive Residential Care Home 26/08/05

Mount Olive Residential Care Home 10/12/04

Mount Olive Residential Care Home 21/07/04

Mount Olive Residential Care Home 27/02/04

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

CARE HOME ADULTS 18-65 Mount Olive Residential Care Home 99 Shardlow Road Alvaston Derby Derbyshire DE24 0HJ Lead Inspector Tony Barker Unannounced Inspection 8th February 2008 13:30 Mount Olive Residential Care Home DS0000001995.V356276.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 Olive Residential Care Home DS0000001995.V356276.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 Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Olive Residential Care Home Address 99 Shardlow Road Alvaston Derby Derbyshire DE24 0HJ 01332 571470 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) Mrs Gloria Emphemia Holness Mrs Gloria Emphemia Holness Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th September 2007 Brief Description of the Service: Mount Olive Care Home is part of the ‘home’ of the Registered Provider, who is also the Manager. It provides care for up to three service users and is situated on the South Eastern corner of Derby, in the area known as Alvaston. A lounge and dining area specifically for service users is provided, and each person has their own bedroom. The Home has a large garden available to service users. Information about the service is made available through the Service User Guide. Mount Olive Residential Care Home DS0000001995.V356276.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 0 star. This means the people who use this service experience poor quality outcomes. The time spent on this inspection was 4.5 hours and was a key unannounced inspection. We spoke to the Manager and the two service users living there at the time of this inspection. Records were inspected and there was a tour of the building. Both service users were case tracked so as to determine the quality of service from their perspective. Survey forms were posted to the two service users and their opinions were recorded by the Manager on their behalf. The Manager gave us additional information after the inspection visit and this information has been included in this report. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire had been reviewed prior to the last inspection. The Manager stated that the service’s fees ranged from £365 to £414 per week. A copy of the last inspection report, from the Commission for Social Care Inspection (CSCI), was not available at the time of this inspection. What the service does well: What has improved since the last inspection? What they could do better: The service users must have a detailed assessment of needs, care plan and risk assessment that are kept up to date and acted upon. Medication for each service user must be stored in a locked area, and kept separately. A record of all money in safe keeping for service users must be kept. All persons working at the home, paid or unpaid must have a Criminal Records Bureau (CRB) check, which has been undertaken, by the service. The Manager must attend Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 6 health & safety courses in Basic Food Hygiene, Fire and Moving & Handling. A quality monitoring tool must be developed and used. All required records must be in place and kept up to date. Equipment and appliances must be serviced and checked regularly. Cleaning materials considered hazardous must be stored in a locked place. Environmental risk assessments must be recorded. 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 Olive Residential Care Home DS0000001995.V356276.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 Olive Residential Care Home DS0000001995.V356276.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): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual written needs assessments, and care plans, were not in place to ensure that service users’ diverse needs could be identified and met. EVIDENCE: The two service users had lived at Mount Olive Care Home for a number of years, and their care is funded through the local authority. There was no up-to date recorded needs assessment in place that reflected their current needs. Also, no care plans had been developed by the service to record details of how service users’ individual needs should be met. However, relatively recent local authority care plan reviews were in place and these gave a broad assessment of service users’ current needs. From discussion with the Manager, and observation of her interaction with the service users, it was clear that she knew their needs very well and was able to meet these needs. There were no staff employed at Mount Olive - the Manager being sole provider of personal care and support to the service users. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 9 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 poor. This judgement has been made using available evidence including a visit to this service. Service users had no individual plans of care to demonstrate that their health, personal and social care needs were being met. EVIDENCE: As previously mentioned, there was evidence of the Manager having a clear idea of service users’ needs, likes and dislikes and preferences and, in discussion and through our observations, she showed that these needs were being met in a person centred way. However, there was a lack of detailed recording of service users’ needs. The local authority care managers’ review reports were the only documents that provided any needs assessment or action plans. The Manager had not developed any individual care plans - so there was no documented evidence that service users’ physical, social, emotional, recreational or educational needs had been considered. This was apart from a short record of needs and implied risks regarding one service user. However, there was little recorded evidence of how these risks should be managed. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 10 There were no recorded risk assessments in place to reflect the potential risks that the other service user was exposed to – in the Home or the community. This person was describes as “needing their independence”. However, since this inspection, the Manager states that she has written a risk assessment for this service user. The Manager produced an appropriately recorded risk assessment relating to a previous service user. It was explained to the Manager that a limited degree, or lack of, written risk assessments leaves the service users vulnerable to not having their needs met if anything were to happen to her. The Manager gave examples of service users being encouraged to take responsible risks. For example, she said she supports one person, with a physical disability, to walk within the Home and provides a wheelchair when out. The Manager also gave examples of the service users making many day-today decisions for themselves, with little need for prompting from the Manager. These decisions included what to wear and what to eat. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 11 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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: There was a good amount of information about service users’ activities, recorded in the daily notes. One person was attending a day centre two days each week and was regularly going out of the Home independently and was able to use public transport. The health of the other service user had curtailed their attendance at a day centre. The Manager explained how one service user used to find activities within and outside the Home fulfilling, before health issues reduced the person’s confidence. The other service user gave an account of activities that they valued and showed, with pride, personal belongings in their bedroom. Both service users were in the Home at the time of this inspection and were watching television in their lounge for part of this time. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 12 Both the service users were going to church twice a week and attended another church evening club each week. One service user spoke of enjoying a cup of tea in the Market Place in Derby and the Manager added that this person is well known by staff and customers in local shops. Both service users benefited from holidays and frequent trips out. Discussion with the Manager indicated that they are treated as part of her family. She and her husband accompany the residents on many of the trips and activities that they take part in. One service user had occasional contact with a close family member and the Manager spoke of encouraging this relative to come to the Home for tea but this had not happened. The other service user had no close family in contact. Neither had any particular friends the Manager said. The Manager gave examples of certain domestic routines, currently or in the past, that promoted the service users’ independence. This included bringing in the dried washing from the garden. One service user was keeping their own bedroom door key and sometimes locked this door, the Manager stated. They also kept a front door key. Food stock levels were very good including fresh fruit and vegetables. There was a large selection of meat in a well-stocked freezer. There were no written menus but the Manager gave a verbal account of a nutritious and balanced diet for the service users. From the Manager’s account, one service user was able to make a cup of tea and a sandwich. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 13 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. Insecure storage of service users’ medicines may lead to their loss. Service users were provided with good personal and healthcare support. EVIDENCE: The Manager confirmed that the service users needed minimal support and guidance with personal care - though neither were left on their own in the bathroom when taking a shower, she added. The Manager gave several examples of routines in the Home being very flexible – for example, rising times and meal times. There were a number of items of equipment in the Home that maximised service users’ independence. These included a stair lift, rising bath seat and wheel chair for outdoor use by one service user. The Manager stated that she monitored service users’ health care needs noting any changes in condition and taking appropriate action. These changes were recorded in the daily notes. These daily notes also indicated that health professionals were appropriately involved in service users’ lives. These included GP, district nurse, dermatologist, audiologist and psychiatrist as well as chiropodist, optician and dentist. It was not easy to quickly identify, from Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 14 the daily notes, these health contacts and we spoke to the Manager about the value of a separate health record. The Manager had, since the previous inspection, provided a medication recording system, so removing a potential element of risk to service users by means of a clear audit trail of medicine prescribed, administered and disposed of. The occasional administration of paracetamol, as a ‘homely remedy’, was recorded in the daily notes. The Manager was recommended to record these occasions on the back of the medicine record in order to simplify the audit trail. Medicines were not being securely stored: they were kept in a tin in an unlocked cupboard in the Manager’s personal accommodation. This practice is unsafe as access to the medicines cannot be fully managed. The tin contained medicines for both service users and for the Manager and this could potentially lead to mistakes. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Procedures for responding to evidence of abuse were in place, with the aim of ensuring that service users were protected. However, the use of their spending money was not being recorded which would enable spending to be tracked and monitored. EVIDENCE: A satisfactory written complaints procedure was in place but it was not in a format suitable to be understood by the two service users – for example, using pictures and/or symbols. The Manager confirmed that she had never received any complaints but agreed that there was nowhere to record one, should this happen. A satisfactory range of written policies were in place that addressed the safety of individuals at the Home - including a policy on safeguarding adults. The Manager stated she had attended training on this topic provided by Derby City Social Services in 2005 and provided a supporting certificate. She stated that she keeps spending money for one resident but still does not keep any records, receipts and signatures, which would ensure that the account activity and resident spending can be justified and audited. A requirement was made on this issue at the last inspection. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were living in a homely, comfortable and hygienic environment. EVIDENCE: Service users were provided with a homely and domestic environment. Each person had their own bedroom, with a door that locks if they wish and with lockable wardrobes. The bedrooms were seen on this inspection and were well personalised. The service users had their own lounge and dining room, although the Manager spoke of spending time with them in their lounge area. The Home was clean and hygienic and there were no unpleasant odours. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 17 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 & 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service’s inadequate checks on the background of temporary staff and the Manager’s lack of updated training could compromise the welfare and safety of service users. EVIDENCE: There were no staff employed at Mount Olive Care Home and all care and support was provided by the Manager. She confirmed that members of her family help out with some of the domestic chores, such as ironing. The Manager stated that she had still not requested Criminal Records Bureau (CRB) checks on the two people who she occasionally calls upon to provide care for the service users when she is absent from the Home. This was a requirement at the last two inspections and potentially puts the service users at risk. Training records confirmed that the Manager had attended some recent training – in subjects such as ‘Smoke Free Legislation’ and ‘Diet and Diabetes’. However, she last attended fire training in October 2005 and Basic Food Hygiene training in August 1999. The Manager showed her awareness of safe practice in First Aid and had attended a resuscitation course in October 2003, although she had not attended First Aid training. There were no records to Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 18 support her statement that she had had Moving and Handling training – which is relevant for the needs of one physically disabled service user. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 19 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): 37,39,41 & 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Poor management practices may significantly affect service users’ safety and welfare. EVIDENCE: The Manager is qualified in general nursing and has a nursing qualification in working with people with learning disabilities. She has worked as a professional carer for 38 years and has owned and managed Mount Olive Care Home for 16 years. There was evidence of her undertaking periodic training and development. She reported that she does not attend any provider meetings or care home association meetings, but does receive support from another local care home owner. There were no quality assurance systems in place, such as service users’ meetings or satisfaction questionnaires from relatives and external Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 20 professionals. The Manager’s comments in the Improvement Plan, sent to her after the previous inspection, and those in the most recent Annual Quality Assurance Assessment (AQAA) questionnaire indicated that the Manager did not fully appreciate the need to review and monitor the quality of service she provides. Many of the records required by legislation for the protection of service users, and for the efficient running of the business, were not in place as noted in this report. Records were in place to confirm that some equipment in the Home had been tested and maintained in a safe condition. However, a gas safety certificate, dated January 2004, referred to a gas cooker and three gas fires, which the Manager confirmed were still in use but which had not been checked for four years. The Manager later stated that one of these gas fires had been taken out of use. The electrical wiring installation certificate was dated September 2002 and the installation should have been rechecked in 5 years time, ie September 2007. The Manager later produced documented evidence of a new wiring certificate issued on March 4th 2008. No annual tests of portable electrical appliances were being made. There was a good range of fire detection equipment in place and these had last been checked in April 2007. Cleaning materials were being stored in two unlocked cupboards in the utility room. These included bleach in both places. The Manager confirmed that one service user made regular use of the refrigerator in this room. An ‘Urgent Action’ letter was sent to the Manager requiring her to store these hazardous cleaning materials in a locked cupboard. The Manager later stated that a lock had been provided on one cupboard and the cleaning materials had been stored in there. There were no recorded environmental risk assessments in place that would support any assessment being made of potential risks to service users within the Home or immediately outside. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 21 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 X 2 2 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 2 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 2 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 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 2 X 1 X 1 1 X Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 22 Yes 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 YA2 Regulation 14(2) Requirement Timescale for action 31/05/08 2. YA6 15(1) 3. YA9 13(4)(c) All people using the service must have an up to date and detailed assessment of needs. This will ensure that their needs are identified and planned for. Previous timescales of 30/04/07 and 31/12/07 not met. 31/05/08 All people using the service must have an up to date, detailed care plan. This must outline the delivery of care in line with the individuals’ assessed needs. This will ensure that people using the service receive person centred support that meets their needs. Previous timescales of 30/04/07 and 31/12/07 not met. Risk assessments must be 31/05/08 written on each service user and reviewed regularly, ensuring that these are acted upon and recorded in their individual plans of care. This will ensure that all risks are identified and appropriate action taken. Previous timescales of 27/02/04, 13/12/05, DS0000001995.V356276.R01.S.doc Version 5.2 Mount Olive Residential Care Home Page 23 4. YA20 13(2) 5. YA23 17(2) Schedule 4.9 6. YA34 19 Sch 2 7. YA35 16(2)(j) 8. YA35 23(4)(d) 30/04/07 and 31/12/07 not met. Medication for each service user must be stored in a locked area, and kept separate from the Manager’s medication, at all times. This will ensure the security of the medicines and reduce the possibility of administration errors. Previous timescale of 31/10/07 not met. A record of all money in safe keeping for service users must be kept. This record must state the date on which the money was received, the date on which it was returned or used, and the reason why. This will enable spending to be tracked and monitored. Previous timescales of 31/10/07 not met. All persons working at the service, paid or unpaid, must have a Criminal Records Bureau check which has been undertaken by the service. This will ensure that service users will be protected from harm. Previous timescales of 30/04/07 and 31/12/07 not met. The Manager must attend Basic Food Hygiene training to ensure service users’ health is not put at risk when she handles their food. Previous timescales of 27/01/04, 13/12/05, 30/04/07 and 31/12/07 not met. The Manager must attend Fire training twice a year to ensure the safety of service users is not compromised at night. Previous timescales of 27/01/04, 13/12/05, 30/04/07 and 31/12/07 not DS0000001995.V356276.R01.S.doc 30/04/08 30/04/08 30/04/08 30/06/08 30/06/08 Mount Olive Residential Care Home Version 5.2 Page 24 met. 9. YA35 13(5) The Manager must attend Moving & Handling training so she can safely work with the service user who has difficulty in moving. Previous timescales of 27/01/04, 13/12/05, 30/04/07 and 31/12/07 not met. 24 A quality monitoring tool must be developed and used. This should include acquiring feedback from service users, relatives and external professionals. This will ensure that people using the service, and their representatives’ feel consulted and their views valued and acted upon. Previous timescale of 30/06/07 not met. 17 All required records must be in place and kept up to date. This will ensure that all required information is available. Previous timescale of 31/12/07 not met. 13(4)(a)(c) Portable electrical appliances, and gas appliances, must be serviced/checked annually. Evidence must be provided to support this in order to demonstrate that service users have been protected from any unnecessary risks. Previous timescale of 31/12/07 not met. 13(4)(a)(c) Cleaning materials considered hazardous by the Control Of Substances Hazardous to Health (COSHH) Regulations must be stored in a locked place. This is to ensure the safety of service users who may not fully understand the dangers involved. The Manager informs us that this has been done. DS0000001995.V356276.R01.S.doc 30/06/08 10. YA39 31/05/08 11. YA41 31/05/08 12. YA42 30/04/08 13. YA42 14/02/08 Mount Olive Residential Care Home Version 5.2 Page 25 14. YA42 13(4)(a)(c) Environmental risk assessments 30/04/08 must be recorded in order that potential risks to service users within the Home, or immediately outside, are clearly identified. 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. 4. 5. Refer to Standard YA17 YA19 YA20 YA22 YA35 Good Practice Recommendations Written menus should be developed to provide evidence of service users’ diet. Records of health appointments, and associated notes, should be kept separately. The occasional administration of paracetamol, as a ‘homely remedy’, should be recorded on the back of the medicine record. A complaints record should be set up on which to record details of any future complaints. The Manager should attend First Aid training to ensure service users receive appropriate treatment in an accident. This was a previous requirement. Mount Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Olive Residential Care Home DS0000001995.V356276.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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