Inspection on 22/11/07 for Mount Vernon Terrace Care Home

This inspection was carried out on 22nd November 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 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 22/11/06

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 Karmon Hawley Unannounced Inspection 22 November 2007 10:00 Mount Vernon Terrace Care Home DS0000002236.V348260.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.V348260.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.V348260.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 978 4345 0115 978 3822 harun.holmes@ntlworld.com 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.V348260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 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 service’s certificate remains current and reflects the services currently provided. 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 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 £298.21. The cost of hairdressing and chiropody are not included in this charge. This information is made available on the point of enquiry. A copy of the most recent inspection report was available in the home. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took into account previous information held by the Commission for Social Care Inspection, including previous inspection reports, the annual quality report from the service, the service history and records of any incidents that had been notified to the CSCI since the last inspection. The site visit consisted of a method called ‘case tracking’, which involves identifying individual service users who live at the home, and tracking the experience of the care and support they have received during the time they have lived there. This enables a judgement to be made about the outcomes for people living in the home. The inspector also spent time with staff and service users talking with them and observing the interaction and support staff offered service users. Four service users were spoken with who gave feed back about their experiences. General records maintained by the home were also looked at to ensure these were maintained and provided positive outcomes for service users. What the service does well: What has improved since the last inspection? Each service user is now provided with a copy of the terms and conditions of residence to ensure that they are fully informed of the cost of their care and the service and facilities on offer to them. Records of food provided to services users has improved, thus demonstrating that a wholesome and appealing diet is on offer. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 6 A new boiler has been installed, improving the warmth of the building and ensuring that service users are more comfortable. The damp problem in a service users bedroom has been addressed, affording them more comfort. The top floor bathroom has been reopened for service users to use, ensuring that adequate facilities are on offer. All members of staff now have a criminal record bureau check and two written references on file to ensure service users are protected from unsuitable people being employed to work at the home. Quality assurance systems have been recommenced enabling the manager to audit the quality of the service on offer to service users. Staff have received training in first aid to ensure that service users are further protected and receive emergency first aid if required. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are assured that their needs will be assessed and that staff can meet these before they make a decision to move into the home. EVIDENCE: If possible the manager visits prospective service users in the community prior to admission to carry out a preadmission assessment to ensure that staff are able to meet their needs. Also to assist this process the manager receives appropriate referrals from the community psychiatric nurse or social worker. Prospective service users are able to visit the home and spend time there so they can get a feel for the home before making a decision to move in. one service user spoken with said that they had come and spent the night at the home before they decide to move in. Another stated that their community nurse had helped them in making the move to the home. To ensure that all service users are aware of and agree with the terms and conditions of residence all now have a signed copy within their case notes. On speaking with service users, two were able to explain what services were included in the cost of their care. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in a way, which enhances their independence and ensures that they can make their own decisions and choices. EVIDENCE: Service users undergo various assessments such as the activites of daily living, manual handling, physical heath and mental health needs to enable their individual needs to be highlighted. Plans of care in place were personalised and demonstrated that service users had been involved as their personal choices and preferences were included. Plans of care were based upon supporting service users to maintain their independence and make their own choices where able. The level of support each individual needed was clearly documented within the plan. There was evidence that service users had negotiated their care such as the amount of cigarettes they smoke and this was clearly documented and service users had signed to say that they were happy with these negotiations. Service users spoken with stated that staff were very supportive and they felt that they were able to live their lives as they choose, knowing that a helping hand is there if needed. Staff spoken with Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 10 were able to demonstrate a good understanding of service users needs and the support they may need in meeting these. There was evidence within plans of care to show that the community psychiatric nurse or an advocate if required supports service users. One service user spoken with confirmed that the community psychiatric nurse visits them regularly and that this made them feel more supported. Within plans of care there was evidence that service users had been supported to make their own decisions so they may lead their lives as they wish and partake in the local community either on their own or with support if required. There are links with a day centre where one service user currently visits and service users regularly use the tram service to go into the city centre. Service users spoken with said that staff support them when they visit the local community and help them with their shopping. Appropriate risk assessments were in place within service users plans of care to ensure that they are supported in ensuring that they remain safe. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are enabled to make their own decisions about how they spend their time and are offered support if required to carry out activites of their choosing. Service users are able to maintain contacts that are important to them. EVIDENCE: There are a number of activites available in house such as the television; music centre, videos and a pool table should service users wishes to use these. Also service users are supported in accessing the local community and facilities as they wish. Two service users spoken with said they often spent their time either shopping or occupying themselves, which they were happy with. Another said that they often play pool with their relative when they visit. The inspector was informed that one resident attends a drop-in centre three days a week. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 12 One member of staff spoken with said that the routine of the home was flexible and service users are enabled and supported to carry out their lives as they wish. They said that they have access to care plans and risk assessments so they know the level of support they need. Service users were observed to leave and enter the home as they wish and occupy themselves with various activities. The atmosphere of the home was very relaxed and camaraderie was observed between the service users. Two service users spoken with said that all the residents get on and they have brought each other little Christmas gifts The manager stated to ensure that positive relationships are maintained with family and friends there are no restrictions imposed on visiting. A visitors policy has now been put into place, this was seen and outlines any potential restrictions such as staying over night. Service users spoken with said “staff are very accommodating, visitors are always made welcome,” “I often have visitors, I can see them in private in the other lounge if I want,” and “my visitors are made welcome, I also go and spend time with them at their house.” Service users spoken with offered the following comments about the home, “I am very happy here, it is one of the best homes I have lived in,” “ it is fantastic, the staff are all lovely, they do anything you ask” and “it is ok, I can have a smoke whenever I want, it is comfortable here, nice and friendly.” Service users spoken with also confirmed that staff were always friendly and respectful. The observed interaction between service users and staff was of a good standard. Two service users spoken with said that they could attend church if they wanted to, but they choose not to, they said that the staff in the home are very supportive and people could pursue their religious needs if they wanted. One member of staff confirmed that service users are can practice any religion of their choosing and they would be supported in this. The menu on offer to service users has been updated and now offers service users a wholesome and appealing diet. The day’s menu was on display in the dining area so that service users knew what was available and they could make their choice. There are now records available to demonstrate what meals have been on offer and the choices service users have made in order to reflect that service users are receiving a wholesome diet service users spoken with said “you can always have a cup of tea,” “you can have anything you want to eat, there are always alternatives,” and “the food is ok, there are choices.” The practice of putting milk and sugar in the teapot has ceased so that service users can now help themselves. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not receive age appropriate health care checks, which could potentially lead to ill health being left undetected. Service users are placed at a degree of risk of being administered the wrong amount of medication due to current working practices. EVIDENCE: The manager stated that most of the service users are able to manage their own personal care with prompting from staff. Basic information on what assistance and support each service user requires was included within individual care plans. No specific aids or adaptation to the home were necessary at the time of this inspection. Two service users spoken with confirmed that they are offered support in managing their personal care needs. There was evidence within service users plans of care to show that they have access to specialist services such as the doctor, district nurse and community psychiatric nurse. Two service users spoken with confirmed that they are able to access specialist services, as they needed, however they were unable to confirm that age appropriate screening is obtained such as the well women clinic. The manager was not able to confirm that these checks take place, Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 14 these checks are important in monitoring and maintaining good physical health. Service users undergo an assessment in regard to drug administration and to ascertain if they are able to self-administer their own medication with support to maintain their independence. Evidence of these risk assessments were available within service users personal files. Two service users spoken with said that staff looked after their medication and that they were happy with this arrangement. The medication arrangements were observe during the visit, handwritten entries had not been signed by two members of staff to show that these had been checked as correct, in one instance the handwritten entry did not match the prescription, which could result in service users receiving the wrong amount of medication. The manager now keeps records of medication returned to the pharmacy for disposal to ensure that an audit trail of all medication retuned is available. The manager said that the room temperature was now being taken every day to ensure that medication is stored at the recommended temperature as it can deteriorate and become less effective if stored at higher temperatures, however there were no records available to substantiate this. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know that they can approach staff if they have any concerns and that these will be dealt with appropriately. Service users are protected from abuse. EVIDENCE: An appropriate complaints policy and procedure was in place and on display for service users to access. The service has not received any complaints since the previous inspection. One complaint about the service was received by the Commission for Social Care Inspection in regards to accessing services and facilities and oppression in regards to religion and faith, these issues were explored throughout the inspection and are commented on in the relevant sections of the report. Staff spoken with were able to discuss how they would deal with a complaint should it be received. All service users spoken with stated that they were happy with life within the home and care received they said that staff were very good and listened to them, they felt that they could approach them with any concerns and that these would be addressed. All staff employed at the home have a satisfactory Criminal Record Bureau check in place (a police check to see if an individual has a police caution or criminal record). Four members of staff have undertaken training in safeguarding adults to ensure they maintain good practices, evidence that further staff are booked in on a training course in the near future was seen. One member of staff spoken with demonstrated a good understanding in ensuring that service users are protected and their rights are maintained, they Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 16 understood the policies for reporting abuse should they suspected it has occurred. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A warm and homely environment is maintained, however the current maintenance issues detract from service users comfort. EVIDENCE: Improvement work has taken place since the previous inspection to aid the comfort of service users. A new boiler has been installed which has improved the heating system in the home; all areas accessed during the visit were comfortably warm. Two service users spoken with said that the home was always nice and warm. The damp problem in the identified bedroom at the previous inspection has been resolved. The top floor bathroom has been reopened for service users to use, however this has not been refurbished and a damp problem has also appeared, both of which need to be addressed to ensure that a well maintained and comfortable facility is on offer for service users. A damp problem has also appeared in a bedroom next to the bathroom, the manager said that a builder had been to look at the problem, however there was no evidence available to confirm this. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 18 The carpets in the main stairways are dirty and stained and do not present a clean and comfortable environment, therefore these need to be either cleaned or replaced to promote a well maintained environment. Service users spoken with said that staff work very hard at keeping the home clean and tidy and that they were happy with the facilities on offer to them. As a number of service users have incontinent A number of service users have incontinent issue and wear protective pads, the infection control procedures were discussed with the manager, it was stated that pads are placed in a bag and put in the main household waste, this is not good practice and may result in problems in infection control in the home. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A staff team that work well together supports service users, however the current recruitment procedures put service users at risk of being supported by unsuitable staff. Although staff demonstrated good knowledge and understanding in service users needs, additional training will enhance the care delivery. EVIDENCE: Two members of staff have completed the National Vocational Qualification level 2 (a nationally recognised work and theory based qualification) and one member of staff has commenced level three, which enhances skills and knowledge in caring for people. One member of staff spoken with stated that they felt that completing the qualification has helped their development and understanding of the service user group. There have been no new staff employed in the home since the previous inspection; the manager showed the inspector the new induction package that all new staff would undertake. Four staff personal files were observed to see if staff had been recruited safely to ensure service users are protected form unsuitable people. All files had the required documentation such as two references and proof of identity however Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 20 none had an application form in place. The manager stated that this was because the staff members were relatives. This is not good practice and all employees should have an application form in place to ensure robust procedures are maintained. One member of staff spoken with confirmed that they had undergone a Criminal Record Bureau check prior to commencing employment. Each member of staff has an individual training file. There were noted deficits in health and safety, food hygiene, mental health and challenging behaviour, which if undertaken would enhance service user safety and care received. Additional training in first aid has been undertaken since the previous inspection to ensure that there is a first aider on duty at all times, thus ensuring that service users are able to receive emergency first aid treatment if needed. Two service users spoken with said that they felt that staff were well trained to look after them. One member of staff spoken with was able to discuss how they would deal with challenging behaviour if encountered and discussed how each service users is an individual and may need a different approach. They felt they had learned about mental health issues through experience working at the home, however they would like to attend specific training for this to further enhance their knowledge. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home, which is run and managed by a person who is responsive to their individual needs, who listens to them and acts in their best interests. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and is deemed fit to run the home. He continues to work towards completing the Registered Managers Award (a nationally recognised work and theory based qualification in managing a home.) and has also started a course on the mental capacity act, which will enhance the support service users receive in maintaining their rights and choices. Service users spoken with said that the manager was always approachable and had time for them. The staff member spoken with also confirmed that the manager was approachable and supportive. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 22 The manager has recommenced the quality assurance systems. There was evidence of an audit of the service, facilities and environment taking place and action taken to address any areas of concern. Also 9 service users questionnaires had been returned, all gave positive feedback about the home. Regular service user meeting are held, the minutes of the last meeting were observed and demonstrated that service users had discussed issues such as activites and trips out, the facilities and incidents which affect service users comfort such as ensuring that doors are closed when people are outside smoking. The information provided to the Commission prior to the visit demonstrated that routine servicing such as the gas maintenance takes place, the mains electric and portable appliance testing were available for inspection on the day of the visit, showing that these had been tested as required, thus protecting service users. Water temperatures are now tested on a monthly basis to ensure the safe delivery of hot water to service users. Less than fifty percent of staff have received training in health and safety, however staff were able to discuss relevant issues such as ensuring a safe environment was maintained. Eight members of staff now have the first aid qualification and it is ensure that a qualified first aider is on duty in the home at all times. Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 23 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 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 X 3 X X X 3 Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 24 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 YA19 Regulation 12(1,a) Requirement Timescale for action 25/12/07 2 YA20 13(2) 3 YA25 23 (2) (b) It is required that systems are put into place to promote and make proper provisions for the health and welfare of services to ensure that their physical health is monitored appropriately. 23/12/07 Evidence is required to demonstrate that medication is kept suitably; 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). Systems must be introduced to ensure that entries made on service users medication charts match the prescription to ensure that service users receive the appropriate medication. It is required that the premises 22/01/08 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 the top floor bathroom and bedroom must be investigated and repaired and DS0000002236.V348260.R01.S.doc Version 5.2 Mount Vernon Terrace Care Home Page 25 4 YA30 16(2,k) 5 YA35 18(1,c,i) the carpets in the main stairways must be cleaned or replaced to ensure service users live in a comfortable and well-maintained environment. After consultation with the 22/01/08 environmental health authority suitable arrangements must be made for the disposal of clinical waste to ensure that effective infection control takes place and service users are protected. Systems must be put into place 22/02/08 to ensure that staff undertake all compulsory training to ensure that a well trained and competent staff team care for service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA34 Good Practice Recommendations All staff employed by the service have an application form on file to enable the employer to obtain a clear history of employment and attainment, to ensure that the applicant is suitable for the job description and person specification. An annual business plan would offer further evidence of proposed improvement work to be undertaken, thus enhancing the quality assurance systems. 2. YA39 Mount Vernon Terrace Care Home DS0000002236.V348260.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V348260.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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