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Inspection on 18/09/06 for Mount Pleasant, Camborne

Also see our care home review for Mount Pleasant, Camborne for more information

This inspection was carried out on 18th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Mount Pleasant provides a homely comfortable environment for service users accommodated there. The building is well maintained, and furnishings are to a good standard. Bedrooms are individualised, and have en suite facilities. The building was clean at the time of inspection. Service users said they were happy with the service they received. They enjoyed the food provided and said staff looked after them well. Staff seem professional and caring. There seems a good rapport between the staff group and they seem to have a good awareness of the needs of service users. Staff seemed happy in their work, and found management supportive.

What has improved since the last inspection?

There were no requirements in the last inspection report, and subsequently there does not appear to be any significant developments regarding this service since the last inspection.

What the care home could do better:

The inspection resulted in seven statutory requirements. Action in these areas is required by law, within the timescales set. The registered persons need to ensure the operation of the medication system is improved. For example recording needs improvement, and medication, which is surplus to requirements, needs to be returned to the pharmacist.The home was generally very clean and hygienic, but action needs to be taken to improve the hygiene standards of one service user`s bedroom. A risk assessment, and evidence of consultation needs to be present regarding the current restriction on the service user`s use of their en suite bathroom. A review of staffing levels needs to take place of staffing around teatime. Some service users and staff the inspector spoke to felt there was not enough staff on duty at this time. Otherwise staffing levels appear satisfactory. Staff recruitment and training requires some improvement. The registered persons must obtain two references for new staff. When staff are awaiting a Criminal Record Bureau check they must be appropriately supervised according to government guidelines. There are some gaps in staff training such as infection control, food hygiene, first aid, moving and handling and medication training, which need to be addressed. Although health and safety precautions are generally satisfactory, clearer written guidance must be developed regarding the use of protective clothing e.g. type of protective gloves available for various tasks. Staff views should be considered regarding this issue. Three recommendations are made for good practice. Contemporaneous notes of all preadmission assessments for new service users should be maintained on their files. Separate records should be kept regarding all medical interventions e.g. chiropodist, dentist etc. Staff should attend adult protection training e.g. as organised by the local authority.

CARE HOMES FOR OLDER PEOPLE Mount Pleasant Pentalek Road Camborne Cornwall TR14 7RQ Lead Inspector Ian Wright Key Unannounced Inspection 09:00 18 to 20 September 2006 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Pleasant Address Pentalek Road Camborne Cornwall TR14 7RQ 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) 01209 716424 Mr Alan Herbert Blight Mrs Deborah Jane Blight Mrs Jacqueline Ann Dart Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Mount Pleasant provides care for 19 older people. The home is situated near to the centre of Camborne. The registered providers are Mr and Mrs Blight. The registered manager is Mrs J Dart. The property offers spacious accommodation for service users. Shared rooms include two lounges and a dining room. The majority of bedrooms are en suite and there are no shared bedrooms. There is a pleasant garden, which includes a summerhouse. The ground floor of the home and the garden are accessible to wheel chair users. The upper floor of the home is only accessible via a stair lift. The home also offers a day care service. A copy of the inspection report is available on request. The fee at the time of the inspection is £385 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place in fourteen and a half hours. All of the key standards were inspected. The methodology used for this inspection was: • To case track four service users. This included, where possible, meeting and discussing with the service users their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other service users and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: The inspection resulted in seven statutory requirements. Action in these areas is required by law, within the timescales set. The registered persons need to ensure the operation of the medication system is improved. For example recording needs improvement, and medication, which is surplus to requirements, needs to be returned to the pharmacist. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 6 The home was generally very clean and hygienic, but action needs to be taken to improve the hygiene standards of one service user’s bedroom. A risk assessment, and evidence of consultation needs to be present regarding the current restriction on the service user’s use of their en suite bathroom. A review of staffing levels needs to take place of staffing around teatime. Some service users and staff the inspector spoke to felt there was not enough staff on duty at this time. Otherwise staffing levels appear satisfactory. Staff recruitment and training requires some improvement. The registered persons must obtain two references for new staff. When staff are awaiting a Criminal Record Bureau check they must be appropriately supervised according to government guidelines. There are some gaps in staff training such as infection control, food hygiene, first aid, moving and handling and medication training, which need to be addressed. Although health and safety precautions are generally satisfactory, clearer written guidance must be developed regarding the use of protective clothing e.g. type of protective gloves available for various tasks. Staff views should be considered regarding this issue. Three recommendations are made for good practice. Contemporaneous notes of all preadmission assessments for new service users should be maintained on their files. Separate records should be kept regarding all medical interventions e.g. chiropodist, dentist etc. Staff should attend adult protection training e.g. as organised by the local authority. 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 Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 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 Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 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 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The registered provider’s statement of purpose and service user guide are satisfactory, so service users and their representatives receive suitable information about services offered. Service users receive a copy of the home’s terms and conditions of residency or a contract, so they have information regarding their rights and responsibilities. The pre admission assessment procedure is good, and enables the registered persons to ascertain they can meet the needs of service users, before admission is arranged. EVIDENCE: Copies of the registered provider’s statement of purpose and service user guide were inspected and are satisfactory. The manager said a copy of this document is in each bedroom. A copy of the home’s terms and conditions of residency / contact was contained in service user files. The registered manager assesses service users before admission is arranged. Staff said service users or their relatives could visit the home before formal admission is arranged. Some service users said an assessment was completed before admission was arranged. Copies of assessments were available for Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 9 inspection in service user files. One service user came to the home from near London, and the registered persons were unable to visit the service user before admission. A copy of the nursing assessment was obtained from a hospital where the service user was residing, and the registered manager said she completed an assessment over the telephone. This seemed a satisfactory process considering the situation. However, the registered persons are advised to keep any contemporaneous notes of assessments completed and ensure these are available for inspection. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 10 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): Quality in this area is adequate overall. The judgement has been made using available evidence including a visit to the service. All service users have a satisfactory care plan, and these are suitably reviewed. These help to ensure service users’ care needs are suitably met. Healthcare support seems appropriate so service users can be assured they will receive suitable support from medical practitioners. The operation of the medication system needs improvement, so service users can be assured their medication is handled appropriately. Issues regarding the diverse backgrounds of service users appear suitably addressed. Service users have said they feel they are treated with respect and dignity. EVIDENCE: There is a copy of a care plan in each service user file. Staff said care plans were accessible to them. The care plan format is satisfactory and individual care plans are reviewed regularly. Service users the inspector spoke to did not seem aware of care plans but they said care is delivered to a good standard, and staff did their best to meet their needs. The manager said reviews occur with the service user and the service user signs to state this has occurred. Service users said they were satisfied with the healthcare support they received. This includes visits from GP’s, district nurses, chiropodists, dentists Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 11 and opticians. The inspector spoke to two district nurses who were very happy with care practices within the home. GP visits were recorded appropriately, but visits by other medical professionals should be recorded separately from the daily notes. Current practice makes it difficult to track, for example, when a service user last saw a dentist. One service user said he would like the see the GP regarding his eye. The registered manager said an appointment has been arranged. The registered providers have a satisfactory medication policy. Medication is administered via the monitored dosage system. The medication system was inspected. The following issues must be addressed: • Administration. ‘One or two’ Lorazepam tablets are prescribed to be taken ‘up to twice a day if needed.’ However this was being administered as ‘one four times a day,’ and not as required (PRN). The inspector spoke to a member of staff regarding this, and she stated the GP said the medication could be administered this way. However such instructions need to be confirmed in writing. The registered persons should, as part of the service user’s care plan, draw up instructions for staff outlining under what circumstances PRN medication should be administered. • Record keeping. Some medication was signed for when it was not administered, and some medication was not signed for when it was administered. All medication kept in the home must be recorded on medication sheets. • Storage. Medication, which is no longer required, must be disposed of. For example Movicol medication was still in stock which was prescribed for an ex- service user on 24/12/2005. Medication no longer required must be returned to the pharmacist. Care must be taken not to obtain more medication than is required when medication is ordered. Some medication also had labels removed for example Normacol, Movicol and Aspirin. Medication administered to individuals must be prescribed to them only. The operation of the medication system is unsatisfactory, and the registered manager must take urgent action to ensure the above problems are rectified. The registered manager should consult the Royal Pharmaceutical Society Guidelines as a baseline regarding how the system needs to operate. Service users said they felt staff worked with them in a manner, which respected their privacy and dignity. Service users were positive about their care. Service users said personal care was provided to a good standard. The registered provider has a satisfactory policy regarding anti discrimination. There are currently no service users from ethnic minorities, although staff stated the home would be more than happy to accommodate service users from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality, gender and disability seem to be suitably addressed. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 12 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, 15 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Routines and activities are satisfactory although some service users have said they would like the opportunity to go out on social trips. Visiting arrangements are flexible. Appropriate arrangements appear to be in place regarding the management of service user moneys. Meals are provided to a good standard, so service users receive a wholesome and nutritious diet. EVIDENCE: Service users said they could get up and go to bed when they wished. The inspector observed staff working in an appropriate matter with service users. The morning routine of assisting service users to get up was unrushed and appears to take individual wishes and needs into consideration. Service users either spend time in one of the lounges or in their bedrooms. There are some organised activities for example an entertainer visits the home. There was a summer fete recently, and service users can go to see the Christmas lights in a minibus if they wish. Other activities such as board games and quizzes are organised. Service users said they could receive visitors when they wished. Some service users expressed to the inspector, and through the registered persons satisfaction questionnaire, that they would like more external activities. However the manager said she periodically arranges trips Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 13 out. The registered persons said a religious minister visits regularly. Activities are recorded in an ‘activities book.’ No moneys are maintained on behalf of service users. The registered manager and her staff do some shopping on behalf of service users who are subsequently invoiced for any purchases. Service users said they either control their own finances or they have power of attorney arrangements. Service users said they felt their personal belongings were safe and secure in the home. The registered persons have said service users have a security box in the bedrooms. Service users have their meals either in the dining room, or their bedrooms. The inspector shared lunch with service users on the first day of the inspection. The meal was to a good standard. All service users said they enjoyed the food provided. If service users do not like the main meal on offer, an alternative is provided. A choice of a hot and cold evening tea is offered, and it seems significant effort goes to ensuring there are a suitable variety of options available. Suitable records of food provided are maintained. Special diets (e.g. pureed meals) are provided as required. Some comments were made regarding the need to improve staffing levels at tea time- this issue is discussed in the ‘Staffing’ section. Some service users said they would like fresh fish, and also more fruit. The registered persons said this was already provided. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 14 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, 18 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The registered persons have suitable procedures regarding complaints and adult protection. Subsequently service users can be assured there are appropriate procedures to deal with any concerns or bad practice. EVIDENCE: The registered persons have satisfactory procedures regarding complaints and adult protection. Staff and service users showed some awareness of the procedures, and were able to say whom they would approach if they had a complaint or were concerned about abuse. No complaints have been received by the Commission for Social Care Inspection. There were no complaints recorded in the Complaints Book since the last inspection. The registered providers should try to arrange some training regarding abuse and adult protection for example via the local authority. Staff and service users all said they had not witnessed any bad or abusive practices. The majority of staff have Criminal Record Bureau check, and a Protection of Vulnerable Adults check (where applicable). Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 15 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, 24, 26 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. Mount Pleasant provides a pleasant, homely, clean and well-maintained environment for service users to live and feel at home in. EVIDENCE: The building was inspected. The building appears to be well maintained, clean, pleasantly decorated and homely. There is a pleasant garden, which service users can use. All communal rooms are homely and comfortable. There are two lounges downstairs. Bedrooms are individualised and comfortable. However one bedroom had several stains on the carpet and an unpleasant odour and this needs attention. The registered manager said the service user was registered blind and would occasionally spill fluids. The person’s ensuite toilet door was locked to prevent the service user using it. The manager said the reason for this is there might be a health and safety risk. However, this matter was not risk assessed, and there needs to be documentary evidence that the matter had been agreed with the service user and the person’s representatives. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 16 A stair lift is provided to assist service users to go upstairs. Suitable bathroom facilities are provided. Suitable kitchen and laundry facilities are provided. The home was clean and hygienic at the time of inspection. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 17 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, 30 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Staffing levels appear to be generally adequate although staffing levels need reviewing around teatime. Recruitment records are adequate, although two references need to be obtained when staff are recruited. Staff who are awaiting Criminal Record Bureau clearance need to be supervised according to published guidelines. This will help assure service users that they are in safe hands. There are some gaps in training required by regulation. Suitable training will assure service users that staff have suitable skills and knowledge to cater for their needs. The registered persons have a good approach to ensuring staff have a national vocational qualification in care. Equal opportunities issues regarding recruitment and work practices seem satisfactory. EVIDENCE: Rotas show three members of staff are on duty in the morning, two in the afternoon, and two staff in the evening until 2300. There is one waking night staff on duty, and one member of staff sleeping in. Although staffing levels appear generally adequate, some staff and service users commented it would be beneficial to have an additional member of staff on duty around teatime. This was because one carer was involved in meal preparation, leaving the other carer to provide support for all service users. This could present a health and safety risk. The matter could be resolved by ensuring the evening member of staff worked between 16:30 and 23:00 rather than 17:30 to 23:00. The manager has agreed to review staffing levels at Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 18 evening tea time. The review should take staff and service user views into consideration. The registered providers have a suitable approach to providing National Vocational Qualifications for care staff. The pre inspection questionnaire states 75 of staff have an NVQ 2 or 3. Staff training records were inspected. Staff training required by regulation needs some improvement. Some staff need to have one or more of the following areas of training i.e. medication, first aid, manual handling, infection control and food handling training. The registered manager said moving and handling, health and safety and medication training is due to take place in the next three weeks. The registered manager said some staff also have completed infection control training as part of their NVQ programme. There are satisfactory records of staff induction. Recruitment records were inspected. Most recruitment and personnel records were satisfactory, although there was only one reference each for two members of staff. One member of staff who commenced employment in July 2006 did not have a Criminal Records Bureau check. The registered persons said this had been applied for. However suitable levels of supervision should be provided until the check is returned in line with Criminal Record Bureau guidelines. The registered provider’s approach to equal opportunities and anti discrimination is satisfactory. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 19 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, 38 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. The registered persons appear to be suitably experienced and qualified to manage the home. The registered persons approach to quality assurance is good and should assist the registered persons to assess and improve the quality of service. The registered persons do not handle any moneys on behalf of service users. The management of health and safety issues is generally satisfactory although the registered persons approach to the provision of protective clothing needs improvement. EVIDENCE: The registered persons appear to have suitable experience and knowledge to manage the home. The registered persons have a suitable quality assurance policy. The registered manager has completed a survey of service users and their representatives, which has concluded positive outcomes for service users in most areas. The staff team have received letters and cards of thanks from relatives for care given to service users. Staff and service user meetings have taken place at least twice over the last year. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 20 The registered persons do not look after any service user moneys or act as agents for service user government financial benefits. The registered provider has a health and safety policy. Records kept of checks required by regulation are satisfactory. For example there are suitable records for the testing of fire equipment, gas appliances, moving and handling equipment and portable electrical appliances. Work is currently being undertaken on the electrical hardwire circuit before a replacement certificate can be issued. Accident records are suitably maintained, and suitable risk assessments are in place to minimise the risk of falls. Health and safety risk assessments are satisfactory. There are some gaps in health and safety training as highlighted in the ‘Staffing’ section of the report. Some staff were concerned about the quality of protective gloves provided for personal care. As a consequence some staff were bringing in their own latex gloves. The registered manager said latex gloves were provided, for example, for clearing up bodily fluids, but staff did appear to have to use a polythene type of glove for other personal care. The registered manager said the polythene glove was used due to what was considered the over usage of latex gloves. The inspector observed the polythene type of glove and these do not appear to be satisfactory. The registered manager has agreed to clarify, via written guidance, what glove should be used for what task. The registered persons should consider staff concerns and preferences in this guidance. Mount Pleasant DS0000009165.V308609.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 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 3 X X X X 2 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 (2) Requirement Timescale for action 31/12/06 2. OP9 3. OP24 4. OP27 5. OP29 The registered persons must operate a suitable system for the storage and administration of medication (for example in line with the Royal Pharmaceutical Society guidelines.) 13 (2) The registered persons must maintain at all times medicine administration records which are up to date and accurately detail the administration of medicines to service users. 13, 16, 23 The registered manager must: • Ensure one of the service user’s bedrooms is kept clean and hygienic. • Risk assess the restriction placed on this service user not being able to use their en suite facility (in consultation where appropriate with the service user and their representatives.) 18 The registered persons are required to review staffing levels at evening teatime as outlined in the report. 19 The registered persons must DS0000009165.V308609.R01.S.doc 31/12/06 31/12/06 31/01/07 31/12/06 Page 23 Mount Pleasant Version 5.2 ensure two references are obtained for new staff employed. 6. OP29 12, 13, 19. Staff awaiting Criminal Records Bureau clearance must receive suitable supervision according to government guidance. 18 The registered persons must ensure staff receive training appropriate to the work they perform. This must include training required by regulation for example first aid, infection control, food handling, and manual handling. 13, 16, 23 Staff must be provided with suitable protective clothing. The registered persons must provide written guidance regarding what protective clothing is provided for which tasks. Staff views should be considered as part of this guidance. 31/12/06 7. OP30 01/02/07 8. OP38 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3. Refer to Standard OP3 OP7 OP18 Good Practice Recommendations Keep any contemporaneous notes of preadmission assessments completed. Keep suitable records of all medical interventions e.g. dentists, chiropodists etc. Arrange staff to attend local authority adult protection training. Mount Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Pleasant DS0000009165.V308609.R01.S.doc Version 5.2 Page 25 - 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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