CARE HOMES FOR OLDER PEOPLE
Mount Pleasant 18 Rosemundy Lane St Agnes Cornwall TR5 0UD Lead Inspector
Lynda Kirtland Unannounced Inspection 16th February 2006 11:00 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 DS0000008913.V273124.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Mount Pleasant Address 18 Rosemundy Lane St Agnes Cornwall TR5 0UD 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) 01872 553165 01872 275289 Mr Godfrey William Sear Mrs Susan Ann Sear Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Mount Pleasant is a care home located near the centre of the village of St. Agnes. The registered providers are Mr G Sear and Mrs S Sear. Mount Pleasant provides accommodation and personal care for up to 22 older persons. The accommodation for service users and the communal areas are on one level; there is full access around the home for all service users. Corridors are wide to suit service users who use a wheelchair. The first floor accommodation is for staff, and a member of staff sleeps in on call in the upstairs accommodation. There are 20 rooms of which 18 are for single occupation and two shared rooms. The majority of service users’ bedrooms have an en-suite toilet and washbasin facilities. Communal areas and service users’ rooms are decorated and furnished to a good standard. The kitchen area has been upgraded and was clean and well ordered. The house is set in well laid out gardens, with fine views of the town and countryside. There are parking spaces to the front of the property. The home is close to all local amenities with access to transport links into the main town of Truro. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspector visited Mount Pleasant Residential Home on the 16 February 2006 and spent four hours at the home. This was an unannounced visit. The purpose of the inspection was to gain an update on the progress of compliance to the requirements that were identified in the last inspection report dated 23 June 2005 and the follow up inspection visit which occurred on the 10 November 2005. In addition the inspector focused on the following key areas of care: choice of home, care planning, health care, leisure, complaints, staffing and some management areas. On the day of inspection 21 service users were resident in the home. The methods used to undertake the inspection are to meet with a number of residents and staff to gain their views on the services that Mount Pleasant offer. Mount Pleasant records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. The registered provider was not present during this inspection, however she was made aware that the inspection was occurring and stated she would arrive to see the inspector and bring relevant documents from her home to Mount Pleasant. She did not bring the relevant documents to the home and due to her late arrival, and previous commitment was unable to meet with the inspector. Therefore the inspector met with staff that was in charge of the morning and afternoon shifts. The inspector would like to thank service users and staff for their cooperation during this inspection process. What the service does well:
Service users stated that Mount Pleasant provides good care and the majority of residents commented that the staff are ‘kind’ and ‘caring’. The majority of residents commented that they felt that staff met their care needs. Service users commented that they have access to health care and felt that all their health needs were met to a ‘good’ standard. The majority of service users commented that they are satisfied with the quality and quantity of food. Service users commented that there is a ‘warm welcome’ to the home by staff when they arrived and on each occasion when they receive visitors. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 6 From this inspection it was evident that the registered provider ensure that the accommodation is maintained to a good standard. Service users commented that they were ‘happy’ with their private rooms and the communal areas. The home has well maintained gardens that are used regularly by all who live or visit the home. What has improved since the last inspection? What they could do better:
At the last inspection 23 requirements were identified of which the registered manager has complied with four. It is of concern that 18 requirements are re notified to the home. From this inspection further requirements have also needed to be identified in the areas of training and the management of service users monies. The total amount of requirements to be addressed is 22 with 3 recommendations. It is of concern that of the 18 requirements re notified to the home there is no or minimal evidence to demonstrate that any work has been undertaken to address them. This inspection demonstrated that pre admission assessment, which ensures that resident’s needs are identified and clarifies that the home can meet their individual care needs, is not occurring. There was no evidence to show that service users were able to make an informed choice about moving into the home. For some service users there are no individual care plans. Of those that did have a care plan the registered provider must continue to develop the care planning and review process in order that individual care needs are identified to enable staff to approach the individuals care need in a consistent manner. Resident’s social, educational and leisure pursuits must be identified and promoted in the home.
Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 7 Staff must attend training in respect of tracheotomy and epilepsy to ensure that they can meet the current needs of service users resident in the home. In addition they must attend mandatory training. The homes complaints process must be promoted to ensure residents and their representative’s feel able to raise any concerns, be listened too and that there will be no repercussions on their care. The adult protection policy must be amended to ensure that correct procedures for instigating adult protection concerns are carried out correctly. All staff must receive training in this area. Records in respect of staff recruitment, supervision, training must be kept on site and available for inspection. Staff access to training, supervision and appraisal’s must occur to promote and encourage updated working practices in the home. The registered provider must ensure that the homes records are in line with regulations and reviewed annually. Staff informed the inspector during this inspection that the registered providers are aiming to return to live on site for approximately four months. Some staff felt that their absence had a consequence in that the homes systems and procedures had declined and hope that the continual presence of the registered providers may have a positive effect on the home. Due to the level of concern surrounding the number of requirements that have been re notified to the home, in some occasions for the fifth and sixth, CSCI will meet with the registered provider to discuss the importance of this further and to explain the possible legal consequence if positive arrangements are not put in place. 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 DS0000008913.V273124.R01.S.doc Version 5.1 Page 8 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 DS0000008913.V273124.R01.S.doc Version 5.1 Page 9 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): 3,4,5, No progress has been made to improve the admission procedure to ensure that there is a proper assessment prior to residents moving into the home. The home also experience difficulties in obtaining assessments that have been completed by statutory agencies. This makes the assessment arrangements unsatisfactory. Service users experienced a positive introduction to the home. Staff training in providing care to service users with complex care needs is absent which could place service users at risk. EVIDENCE: At the previous inspection a requirement was identified for the registered provider to ensure that all residents prior to admission to the home undergo a pre admission assessment to identify if the placement is suitable for the service user and the home. From inspection of three files of service users who had been recently admitted to the home there was no documented evidenced that a pre admission assessment had taken place. In addition there was no information from referring agencies to assist in the pre admission assessment. The consequence of this is that the home admits service users with no or
Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 10 limited knowledge of the individuals’ physical, emotional, social, educational and leisure needs. Staff confirmed that they did not know the service users care needs until they ‘arrived’ at the home, and they met them. This is unacceptable practice as the home is not undertaking any preadmission assessment to ensure that they can cater for the service users individual needs, and for the service user they are not able to make a informed choice as to how their care needs will be met. CSCI are concerned as this is now the sixth time this has been brought to the registered providers attention and no improvements in this area has been made. From discussion with service users they stated that they ‘knew’ about the home before their admission and felt that staff welcomed them on arrival. However the inspector shared concern with staff and some service users that some care needs were not able to be met by the home appropriately as they were too complex. Training for staff in complex care needs such as the use of tracheotomy and epilepsy have not been provided to the staff group. Yet they are providing care to some service users who need this level of care. There was no evidence in the recently admitted service users file that a months trail period was offered to all new residents or a review is held with all parties present to consider if the placement is appropriate long-term. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 All service users must have a care plan, which identifies their care needs accurately, and states what staff interventions are needed to ensure consistency of care delivered. Residents’ health needs are met in a satisfactory manner. Medication systems have improved to ensure that the administration of medications is safe. The staff at the home aim to build positive relationships with residents that are based upon the resident’s dignity and privacy. EVIDENCE: Previous requirements have been identified for the registered provider to develop individual care plans that accurately describe what skills residents are able to self manage and where staff interventions are needed to approach a specific care need and meet the preferences and choices of residents. The care plan must also include social, educational and leisure needs. From inspection of three recently admitted service users to the home, no care plans were completed. On inspection of a service user who had been living at the home for sometime, there was a care plan on the file, but this did not identify what interventions staff must take to address the care need in a consistent manner.
Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 12 The arrangements for care planning and risk assessments for residents need to be reviewed and developed further. The inspector has offered to visit the home on a couple of occasions to discuss the care planning process but the registered provider has not taken this up. Therefore these requirements have been re notified to the registered provider. From discussion with service users they were unaware of their care plans and commented that they had not been involved in their development or subsequent review. From discussion with service users the majority commented that they felt that they received satisfactory care. Positive links are maintained with the local primary health care services The General Practitioners and District Nurses visit the home when needed. Service users stated that they felt that all their health needs were identified, appropriate action taken, and follow up treatment provided by the home and local health services was ‘good’. However the home was providing care to some residents with complex needs i.e. tracheotomy and epilepsy and no training in these areas of care have been provided to the staff group. This must be addressed urgently. Due to previous requirements in respect of medication the inspector at the follow up visit observed a medication round which was carried out by a knowledgeable member of staff. The inspector observed her administering medication appropriately and completing the MAR sheets. A tablet count crossreferenced with the MAR sheets. Staff confirmed that they had attended a refresher course in the safe handling of medications. Staff were now aware of where the medication policy/procedure is located so that they can refer to it. Currently the home has no prescribed controlled drugs, if this occurs appropriate storage facilities must be installed. Therefore compliance with some medication requirements was met. Staff were unaware if permission from residents in how they want their medication to be managed (either self administer or via the home) was sought and incorporated in their care plans. They were unaware that a risk assessment was undertaken for those residents who self-administer their medication. Therefore these requirements have been re notified to the registered provider. From discussion with service users the majority commented that they felt the staff team ‘were ‘kind’. From inspectors observations of staff throughout the inspection it was noted that staff approached and interacted with service users in a professional yet sensitive manner. Residents confirmed that in the main they have a choice as to when to rise/ retire to bed, receive their mail unopened, have access to a private phone and can receive visitors in private. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Mount Pleasant provides a limited programme of activities to promote and encourage the pursuit of residents social, educational and leisure needs. Flexible visiting arrangements are in place and visitors are welcomed at the home. The majority of service users were satisfied with the provision of food in the home. Staff must have appropriate training to work in the catering area. EVIDENCE: From discussion with service users there was a variation in view about the level of activities in the home. Some felt there was ‘enough to do’ and others felt that the level of activities was lacking. Residents recalled the weekly activities as keep fit and a sing-along and that there were extra activities organised over the Christmas festivities. In discussion with staff they commented that the home have attempted to organise outings which have later been cancelled by residents. From discussion with service users and staff they are unaware of meeting with the registered provider to discuss with them the level of activities in the home and how this can be improved. Social, educational and leisure interests must be included in residents care plans, as this is currently not occurring. Therefore this requirement remains re notified. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 14 There is a flexible visiting policy and residents determine where they meet with their guests. Staff informed the inspector that a cook was no longer employed at the home. However a member of care staff was taking over this role the following week, she has no basic food hygiene or intermediate food certificate and if continues to be in this post these qualifications must be gained. Staff informed the inspector that the last cook left due to service users raising concerns about the quality of food. In discussion with service users they did not tell the inspector that there had been a difficulty in this area and in the main stated that they were ‘satisfied’ with the food. A menu book was seen which demonstrated that service users have a choice of two main meals a day and sandwiches at teatime. However this book was completed up to the 29 Jan06 and no further information had been entered for the month of February. Likewise from inspection of fridge/ freezer and probing temperatures of food these sheets were not completed and must be. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Mount Pleasant has an appropriate complaints and whistle blowing policy. Some residents are confident to raise any concerns with staff. Records of complaints and actions taken to resolve them must be recorded. The policy and procedure for protecting resident against abuse needs to be improved. EVIDENCE: Mount Pleasant has an appropriate complaints procedure that is included in the homes statement of purpose and service users guide. CSCI have not received any complaints since June 2006. Staff told the inspector that the home received complaints about the quality of food, and the home resolved this by the cook leaving. However the home does not have a complaints book which evidences how complaints have been received, investigated, and what the outcome or resolution is. Some residents discussed with the inspector the difficulty in raising concerns with the registered provider or staff. The inspector has previously discussed with the registered provider how residents might find it difficult to raise concerns with staff for two reasons. Firstly as mainly family members staff the home and secondly due to this some residents voiced anxiety that there may be repercussions on their care. It was agreed that a residents meeting would be held to give a opportunity for service users to share their views and for the staff to provide reassurance that repercussions on care will not occur. This meeting has not occurred and therefore is re notified to the home. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 16 As the registered provider was not present during the inspection the adult protection policy was not inspected. Staff stated that to their knowledge the policy remains in process. Therefore this is re notified to the home. Two members of staff have attended the Cornwall Multidisciplinary Adult Protection course, and the remaining staff are hoping to attend in the near future. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 17 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): 19,20,21,24,26 Mount Pleasant provides a good standard of décor and furnishings creating a comfortable, clean and safe environment for those living, working and visiting the home. EVIDENCE: From discussion with residents all were satisfied with their accommodation and could not think of any improvements in this area. Their individual bedrooms were furnished and decorated to a good standard, were clean and personalised to reflect the service users character. Access to Mount Pleasant is via a ramp or steps to the main entrance. The accommodation for service users is on one level with no internal steps, and wide corridors and doorways. There are accessible areas for service users in the grounds. The grounds were tidy. The communal areas consist of a large lounge, a dining room and a smaller coffee lounge. The main lounge and dining room are bright and airy. Lighting is domestic in character. The furniture in communal areas is of good quality, in good condition, and domestic in nature.
Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 18 There are sufficient toilet facilities with a variety of adaptations to assist in the transfers of service users. There are well-sited grab rails. Service users had a range of individually assessed equipment – for example walking sticks and frames, wheeled walkers. Space for car parking is good. The premises appeared well maintained. There is an emergency call system. The home is centrally heated by electric storage heating. All rooms have opening windows for ventilation. Lighting is domestic in style and appeared of sufficient intensity. From a tour of the home the accommodation appeared clean throughout. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 19 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): 28 Staff training must be developed to ensure that their awareness of older persons care is developed and put into practice. Staff files must be located on site so that they can be inspected to ensure that appropriate staff are employed in sufficient numbers with robust procedures. EVIDENCE: As the staff could not locate staff rotas this could not be inspected, however there appeared sufficient numbers working in the home. A previous requirement for the registered providers to record the hours they have worked at the home was unable to be evidenced during this inspection. Therefore this has been re notified to the home. Staff told the inspector that all staff is attending a minimum of NVQ level 2 training and aim to complete this by July 2006. Two senior carers have achieved the NVQ level 3, confirmed in writing from the local college. Current ratio of staff trained to a minimum of NVQ level 2 is 30 . Staff were initially reluctant to attend this training but all staff spoken with said how much they have valued the training and want further training. Staff confirmed that the following mandatory training, food hygiene, moving and handling, first aid, infection control has not occurred. This must occur. As staff files were not on the premises and were not brought into the home as requested of the registered provider this could not be inspected. Staff files must be on site and available for inspection at all times as per the regulations of the Care Standards Act 2000. This requirement as to records being on site is re notified to the home.
Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,37,38 There is an absence of mandatory training for the registered provider and staff team. To promote good working practices these must be implemented. Service users have stated they would like to be more involved and consulted about the services that the home provides. A policy in the management of service users monies must be implemented to ensure that service users monies are protected against financial abuse. Records in the home must be reviewed annually to ensure that they are accurately reflect the services and processes that the home provides and promotes. Records as per the Care Standards Act must be on site and therefore available for inspection at all time. EVIDENCE: The majority of service users commented that in the main they felt the care they received at the home was ‘good’. Some residents commented that they would like to be consulted more about the homes facilities/ provisions. Since
Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 21 the last inspection and follow up visit, despite the requirement for service users views to be sought, nothing in this respect has been arranged. Therefore this is re notified. The quality assurance system could not be located and therefore this could not be inspected. The registered provider oversees small amounts of monies on behalf of service users. Records of these transactions were shown to the inspector. Individual spending is recorded in a notebook which records the amount received, spent and dated. However there is no evidence that the service users have agreed to any expenditure or evidence that they received any monies. Evidence that the service users has granted permission for the registered provider to care for small amounts of their monies and all transactions must be evidenced. In addition staff were unaware that there was a policy in the management and administration of service users monies – this must be implemented. As staff files were not on the premises records in respect of supervision and induction could not be inspected. The storage of records is in the main stored in a confidential manner and the majority are in line with the Data protection Act. The inspector reminded staff to be more aware of what they record in the staff handover book to ensure that personal details of service users is not included there. Service users records must be developed further to meet the requirements of the national minimum standards. Records as per the requirements of the Care Standard Act must be located on the premises and available for inspection. The homes policies must be reviewed on a yearly bases to ensure that they still reflect the practices of the home. Certificates in respect of the maintenance of the home were not presented to the inspector despite requests. After some finding the accident book was shown to the inspector and this was satisfactory. Staff told the inspector that training in the areas of infection control, moving and handling, food hygiene and first aid have not occurred. These must occur. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 1 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 1 1 X 1 X 2 1 Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 23 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 OP3 Regulation 14 Requirement The registered person must assess all service users before they are admitted to the home. Seventh notification Care plans must be developed further to ensure that they inform, guide and direct staff in the interventions needed to provide specific care. 6th notification The registered person must: i) keep the service users plan under review in consultation the service user and/ or representative. ii) Make the service users plan available to the service user and /or representative and notify them of any revision. (Sixth notification) A risk assessment must be undertaken for those service users who wish to selfadminister medications. 3rd notification Timescale for action 30/04/06 2. OP7 15 30/04/06 3. OP7 15 30/04/06 4. OP9 12 30/04/06 Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 24 5. OP12 16 Service users social, educational and leisure pursuits must be included in their individual care plan and actively pursued. (Fifth notification) The registered provider must consult service users to promote the complaints process and provide reassurance that there will be no repercussions on their care provision. 3rd notification The registered provider must ensure that all staff at the home are aware of the adult protection policy and procedure and attend relevant training in this area. (Fourth notification) The registered person must retain in the care home the staff records listed in Schedule 4.6 (third notification) The registered person must obtain Criminal Records Bureau disclosures for all persons employed. (Third notification) The registered person must provide a list to the commission of the disclosure numbers of all persons currently employed. (Third notification) Staff who prepares food must have a current food hygiene certificate. 30/04/06 6. OP16 23 30/05/06 7. OP18 13,18 30/05/06 8. OP29 17 30/03/06 9. OP29 19 30/12/06 10. OP29 19 30/12/06 11. OP30 18 30/06/06 12. OP30 18 Individual staff training and 30/05/06 development assessments and profiles must be introduced and kept in respective staff files. A written annual training programme must also be established. (Second notification)
DS0000008913.V273124.R01.S.doc Version 5.1 Page 25 Mount Pleasant 13. OP31 7,8,10,18 The registered provider must be 30/03/06 on duty in the home on the basis of a full time post or employ a registered manager as a full time post. The provider must confirm in writing to the commission how they intend to address this issue. The registered provider must include on the staff roster the hours they are on duty or provide other evidence of how much time they spend on duty in the home. Sixth notification The register provider must demonstrate that she has undertaken periodic training to update her knowledge/skills, competence and experience in the managing the home. Fourth notification Service users and their representatives must be consulted about the operation of and services provided in the home. Fifth notification 30/04/06 14. OP31 10 15. OP32 24, 16 30/05/06 16. OP33 24 The findings of the quality 30/06/06 assurance survey and the actions taken must be forwarded to the CSCI. Fifth notification Staff must receive formal recorded supervision at least six times per year. Supervision should cover all aspects of practice, philosophy of care and career developmental needs. Sixth notification Records must kept on the homes premises and in adherence to Schedule 2,3 and 4 3rd notification Training in complex care needs of tracheotomy and epilepsy
DS0000008913.V273124.R01.S.doc 17. OP36 18 30/05/06 18. OP37 17 30/03/06 19 OP30OP4 18 30/04/06
Page 26 Mount Pleasant Version 5.1 20 OP5 14 21 OP35 12,17,20 22 OP30OP38 23 must be provided to the staff team in order that they can provide this care appropriately. The registered provider must not provide accommodation to service users unless there has been appropriate consultant with the service users or their representative. A policy in the administration of service users monies must be implemented. In addition service users permission must be sought for the registered provider to manage their monies and evidence of all transactions must occur. Mandatory training for staff must occur – especially in the areas of infection control, moving and handling, food hygiene, and first aid. 30/05/06 30/05/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP16 OP38 OP28 Good Practice Recommendations The complaints policy should be amended to state that complaints could be made to CSCI at any time. All policies and procedures should be signed and dated, and reviewed annually. A minimum of 50 of staff should have gained the NVQ at Level 2 qualification. Mount Pleasant DS0000008913.V273124.R01.S.doc Version 5.1 Page 27 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
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