Inspection on 22/11/06 for Mount Vernon Terrace Care Home

This inspection was carried out on 22nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mount Vernon Terrace Care Home 07/04/09

Mount Vernon Terrace Care Home 06/10/08

Mount Vernon Terrace Care Home 22/11/07

Mount Vernon Terrace Care Home 17/02/06

Mount Vernon Terrace Care Home 22/02/05

Mount Vernon Terrace Care Home 01/12/04

Mount Vernon Terrace Care Home 26/02/04

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

CARE HOME ADULTS 18-65 Mount Vernon Terrace Care Home 23-25 Waverley Street Arboretum Nottingham NG7 4DX Lead Inspector Richard Ramsden Key Unannounced Inspection 22nd November 2006 10:00 Mount Vernon Terrace Care Home DS0000002236.V319791.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 Vernon Terrace Care Home DS0000002236.V319791.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 Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Vernon Terrace Care Home Address 23-25 Waverley Street Arboretum Nottingham NG7 4DX 0115 9784345 0115 9783822 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) Mr Ahmed Rashid Holmes Mr Ahmed Rashid Holmes Halima Holmes Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th February 2006 Brief Description of the Service: Mount Vernon Terrace consists of two large houses in a Victorian terrace situated in a residential area of Nottingham City. The home is registered for up to 16 people with a mental disorder (excluding Dementia and Learning Disability). The premises occupy three floors (including a basement recreational area) and are not adapted to meet the needs of service users with mobility needs. There are no lifts, handrails, or specialist bathing facilities. There are ten single and three double bedrooms available. The new tramline stops directly outside the home and offers easy transport into the city centre. The home does not have a car park, and the parking restrictions in the area can make it difficult to visit the home by car. The home had undergone complete refurbishment and repair following a serious fire. The home was forced to close whilst the damage was repaired and had reopened in November 2005. The weekly accommodation charges are £282.99. A copy of the most recent inspection report was available in the home. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced visit over one day it took approximately 8 hours. It included the inspection of care and other records a discussion with the registered manager and two members of staff. The inspector spoke with four residents. A partial tour of the building was also completed. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history and a Pre-inspection questionnaire completed by the registered manager. Seven completed resident satisfaction questionnaires were also received prior to this inspection. What the service does well: Three of the residents spoken with during this inspection were full of praise for the services offered by this home. They said that the staff are always friendly and respectful and that they ensure that their privacy and dignity is maintained at all times. The observed interaction between staff and residents was of a good standard. The residents stated that they like their bedrooms and confirmed that they can use them at any time. All of the residents spoken with said that the home is kept appropriately clean and tidy. The care plans now contain indicators/warning signs of possible deterioration of the residents’ mental health. They also contain basic information on what support and assistance each resident requires. The residents’ records assessed as part of this inspection showed that peoples health care needs are being appropriately met. The homes medication systems are generally well managed. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: All residents should be provided with Terms and Conditions of Residence documents so that they are fully aware of what services and facilities they can expect to receive within the home. Although the home was substantially refurbished last year there are still some areas of the building, which require further work. Diet records must accurately reflect the meals actually provided for the residents and staff should not put milk and sugar into the residents’ teapots, as this is an institutional practice. To ensure the safety of residents two written references and a satisfactory criminal records bureau checked must be obtained for all staff prior to them commencing employment at the home. The homes quality assurance system should be reintroduced so that residents are confident that their views underpin the development of the services provided at the home. All newly appointed staff should complete an appropriate induction-training course and there must always be a qualified first aid on duty in the home. Staff should explore ways of providing meaningful activities for the resident who has been assessed as unsafe to leave the building without supervision. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 7 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 Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 8 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 Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 9 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): 2,5. Residents’ needs and aspirations are assessed prior to their admission to the home. Not all residents have been provided with a written Terms & Conditions of Residence Document. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents personal records were checked as part of this inspection. Each of the records contained a preadmission assessment, which had been completed by Community Psychiatric Nurse. One person had a Terms & Conditions Of Residence Document, which they had signed to confirm their agreement. This document had not been provided for the other resident who’s records were checked as part of this inspection, even though they had lived in the home for almost a year. The Inspector stated that it is important that all residents are given a copy of this document to ensure they are aware of and agree with the services the home intends to provide. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 10 One of the residents spoken with stated that they did visit the home prior to their admission. The second residents said that he had lived in the home for over 30 years and had wanted to return after it was refurbished following a serious fire. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 11 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. Residents have care plans, which reflects their assessed and changing needs and personal goals. People are encouraged and assisted to make decisions about the way in which they wish to live. Residents are supported to take risks as part of an independent lifestyle. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two care plans were viewed as part of this inspection. Both plans contained information on how staff should support residents in their daily lives. Each had a separate section detailing the individual residents mental health needs. One resident who is over 65 is having the physical and health care sections of his care plan reviewed on a monthly basis. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 12 Both residents have signed their care plans to confirm their involvement in the planning and review process. Risk assessments had been completed with both residents prior to their admission to the home and these were the being reassessed as part of the formal review process. Where any limitations had been placed on peoples freedom, following the assessment process, residents had signed to confirm their agreement. None of the residents had contact with independent advocates although all residents had an allocated Social Worker or Community Psychiatric Nurse who they could contact if they were unhappy with any of the services provided by the home. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 13 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. Most of the residents are able to participate in a lifestyle meet their individual needs and aspirations. People confirmed that staff always treat them with respect. People are encouraged to maintain contact with their friends and family. Due to poor record keeping it was not possible to assess whether residents are offered a healthy diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated that all but one of the resident are able to independently access local community facilities. The manager stated that five residents regularly use the tram to gain access to the facilities in Nottingham City Centre. One person said that they prefer to walk into the city when they feel well enough. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 14 The inspector was informed that one resident attends a drop-in centre three days a week and that staff were in the process of trying to persuade another resident to join a gardening group. The residents spoken with during the inspection confirmed that they did not wish to participate in any organised activities. One person said that he attends church in his spare time, another resident said that as he gets older he is happy to spend most of his time watching TV etc. One resident has been assessed as unsafe to leave the home independently. The manager stated that this resident goes out about once a month with staff and that his sister visits him every two weeks. It was recommended that the registered person should look at ways of providing additional stimulation for this resident as it would seem that he only has the opportunity to access community facilities about once a month. The manager stated that visitors are welcome in the home at any time. However when this was discussed further it became apparent that visitors would not be welcome late at night and that there may need to be some restriction on what areas of the home people could have access to. It was recommended that the home produce policy on visitors to ensure that residents and visitors are fully aware of these potential restrictions. The residents spoken with said that visitors are made welcome within the home and confirmed that they could see visitors in the separate lounge if they did not wish to use their bedrooms. The residents spoken with confirmed that staff are always friendly and respectful. The observed interaction between staff and residents was of a good standard. Residents have all been given keys to their bedroom doors and staff do not enter bedrooms unless they are invited to do so. The lunch provided to residents on the day of this inspection consisted of beef burgers frozen peas and mashed potatoes with jelly and cream for pudding. The menu stated that the meal should have consisted of turkey stew with dumplings, mashed potato, broccoli and parsnips. The manager stated that the meal had been altered at the request of the residents. However the residents who were spoken with stated that they had not asked for a change in the menu. The manager confirmed that the lunch on the day prior to this inspection had also been changed but the records had not been altered to reflect this. It was therefore not possible to assess whether a well balanced diet is being provided. One person said that previously the menu had been displayed in the lounge however this had not happened for some considerable time. Three people said that the food provided by the home is “okay”. It was noted that the staff that was making tea to accompany the residents’ lunch put milk in one teapot & milk & sugar in the other. When asked why the Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 15 milk was put in the teapot and not left in a jug so that residents could help themselves the manager stated that it had always been done this way. The inspector stated that this is an institutional practice, which denies residents choice & discourages independence. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 16 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. Where required residents receive appropriate personal support and their health care needs are met. Residents are encouraged to administer their own medication where they have been assessed as safe to do so. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated that most of the residents are able to manage their own personal care with prompting from staff. Basic information on what assistance and support each resident requires is included in his or her individual care plans. No specific aids or adaptation to the home were necessary at the time of this inspection. Residents’ records indicate that their health care needs are being appropriately met. The residents spoken with during the inspection also confirmed this. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 17 At the time of inspection three residents were administering their own medication. The manager is now recorded brief details of the reasons why the other residents have been assessed as unsafe to administer their medication. These residents have signed to confirm that they agreed to the staff administering medication on their behalf. Medication administration records had been appropriately signed. Staff are keeping a record confirming that they have checked all medication received into the home, however the records of disposal of medication indicate that no medication has been returned to the pharmacist since 2004. It is important that the registered person ensures that they keep accurate records of the disposal of medication. The manager was informed that he must ensure that medication is always stored below 25°C as it can deteriorate and become less effective if stored at higher temperatures. The staff who administer medication have all received appropriate training. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 18 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. Residents’ views are listened to and acted upon. They are protected from abuse, neglect & self-harm. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints procedure is prominently displayed in the main reception hall. There have been no formal complaints about the home since the last inspection. The manager has kept a record of minor concerns raised by residents, these records detail what action has been taken to resolve the issues. It is recommended that this information be recorded in a format, which can be viewed confidentially. The home has appropriate Adult Protection Policies & Procedures Including a Whistle Blowing Policy. There have been no allegations of abuse in the home in the last twelve months. The manager has a basic understanding of the local Vulnerable Adults Procedure but none of the staff have received any formal training in this area of their work. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 19 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): 24,25,27,30. Further refurbishment and repairs need to be completed to ensure the home is safe, comfortable & suitable for purpose. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was refurbished approximately 1 year ago following a serious fire. Since then new double-glazed windows have been fitted to the rear of the home, a new washable laundry floor has been fitted and a shower in bedroom one has been boxed to ensure that it doesnt present a potential health and safety risk. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 20 Although considerable amount of work has been completed on the building additional work still needs to be completed. There was only one operational bathroom on the ground floor this room has to be used by 15 residents. Two people said that they sometimes find it difficult having to take turns and they want a bath. The inspector was advised that the bathroom on the top floor has been locked, as it is due for refurbishment. It is essential that this bathroom is made fully functional as soon as possible. Several residents said that they find some areas of the home are not warm enough. One resident said that he finds his bedroom to cold to used during the day. The manager was advised that the home must be maintained at a comfortable temperature, he should seek the views of residents to ascertain if the home is warm enough. One resident had a significant damp patch on his bedroom wall. He said that he would like this to be repaired as he said the fungus resulting from the damp makes him feel unwell. The manager must take steps to ensure that these repairs are completed. The other residents spoken with expressed satisfaction with their rooms and stated that the home is kept clean and tidy. The home has appropriate infection control policies and procedures. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 21 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. Staff are in the process of completing appropriate National Vocational Training. The homes recruitment policies & practices are generally good but do not fully protect the residents. More formalised induction training needs to be provided to ensure that staff can meet the needs of the residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two members of staff had completed NVQ level 2 training and have applied to commence their NVQ level 3 training. The manager is currently completing the Registered Managers Award. Four other members of staff have applied to commence their NVQ level 2 training. Since the last inspection the registered manager has obtained two written references for each of the existing members of staff. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 22 Only one member of staff has commenced employment since the last inspection. This member of staff works part-time at the home while she is completing her nurse training. The manager stated that he had copied the member of staffs existing Criminal Records Bureau Check, as he believed this would be satisfactory. It was also noted that only one written reference had been obtained for this member of staff. The inspector advised the manager that Criminal Records Bureau Checks are not transferable and that a new check and two satisfactory written references must be obtained for every member of staff before they commence work in the home. The commission for social care inspection has received confirmation that this member of staff has applied for a new Criminal Records Bureau Check. The new member of staff had not commenced any formal induction training although the manager stated that she always works with an experienced member of staff. The manager is able to demonstrate that some staff training is being provided this year: this included Moving and Handling, Administration of Medication and Infection Control. However it was noted that only three members of staff had up-to-date first aid qualifications and the staff records viewed during the inspection showed that staff had not attended training on working with people with mental health needs, for some considerable time. It is recommended that a training needs assessment is completed with the whole staff team to help plan what training the home needs to provide to ensure that they can provide a service which meets the needs of the residents. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 23 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): 37,39,42. The manager has considerable experience and is completing appropriate training to ensure that residents will benefit from a well run home. The registered person is not ensuring that residents’ views are influencing the development of the home. The health and safety of residents is generally promoted but the manager must ensure that all staff have up to date training in first aid. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has considerable experience and is currently completing the registered managers award. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 24 The home has an effective quality assurance/quality monitoring system however this has not been updated since 2004. It is important that the manager reinstate the quality assurance process to ensure that the home is achieving the aims and objectives and the statement of purpose of the home. It is noted that the home has regular residents meetings and that any issues raised by residents are acted upon. Where checked the homes health and safety policy and procedures were generally well maintained. The homes Fire records have been appropriately maintained and the registered manager was reminded that all staff must attend at least one fire drill each year. A Legionella risk assessment was completed in 2004 and staff complete a weekly flushing of infrequently used water outlets. It was however noted that staff are not recording water temperatures on a regular basis. The manager was advised to seek advice on this matter from the Environmental Health Officer. Only three members of staff have up to date first aid qualification. The manager was advised that there must always be a qualified first aider on duty in the home at all times. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 2 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 2 X X 2 X Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation 5(1) (c) (d) Requirement It is required that every resident is provided with written Terms and Conditions of Residence Document as part of the homes Statement of Purpose. Timescale for action 01/01/07 2. YA17 16(2)(I)& Schedule 4 (13) 3. YA20 13(2) 4. YA24 23 (2) (p) It is required that the 22/11/06 registered person keeps a record of the food provided for residents in sufficient detail for anyone inspecting the records to determine if the diet is satisfactory. The records must include any special diet/alternative meals provided. It is required that the 22/11/06 registered person shall make suitable arrangements for the safekeeping of medication. This must include recording the temperature each day in the area where medication is stored. Steps must be taken to ensure that the temperature does not exceed the recommended storage temperature. (Usually 25°C). It is required that heating 22/11/06 DS0000002236.V319791.R01.S.doc Version 5.2 Page 27 Mount Vernon Terrace Care Home 5. YA25 23 (2) (b) 6. YA27 23 (2) (j) 7. YA34 19(1) 8. 9. YA35 YA39 18(1) (c) 24 (1) & (3) 10. YA42 13(4) (c) suitable for residents is provided in all parts of the care home used by the residents. The home must be maintained as far as possible at a temperature, which meets the individual residents’ needs. It is required that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. The damp problem in bedroom 5 must be investigated and repaired. It is required that the top floor bathroom is refurbished/repaired and made available to residents It is requires that the registered person ensures that a suitable Criminal Records Bureau Check and two written references are obtained for every member of staff before they commence employment in the home. It is required that staff receive structured induction training. It is required that the registered person shall establish and maintain a process for reviewing and improving the quality of care provided at the home. It is required that staff receive suitable training in first aid. The training must be up to date. A qualified first aider should be on duty in the home at all times. 01/01/07 01/01/07 22/11/06 22/11/06 22/11/06 01/01/07 Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 28 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. 6. 7. Refer to Standard YA12 YA15 YA17 YA22 YA23 YA35 YA42 Good Practice Recommendations It is recommended that the registered person explores ways of providing activities for the resident who has been assessed as unsafe to leave the home without supervision. It is recommended that the registered person produce a written policy on visitors to the home. It is recommended that the registered person ensures that staff stop the institutional practice of putting milk & sugar in the residents teapots. It is recommended that the records of concerns raised by residents be recorded in a format which can be viewed confidentially. It is recommended that staff receive formal training on issues relating to Adult Protection. It is recommended that a training needs assessment is completed with the whole staff team. It is recommended that the registered person seeks advice from the Environmental Health Officer to ensure that The Homes Legionella Risk Assessment is satisfactory. Mount Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Vernon Terrace Care Home DS0000002236.V319791.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!