Inspection on 07/04/09 for Mount Vernon Terrace Care Home

This inspection was carried out on 7th April 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but 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 06/10/08

Mount Vernon Terrace Care Home 22/11/07

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 19/06/2009.

Key inspection report CARE HOME ADULTS 18-65 Mount Vernon Terrace Care Home 23-25 Waverley Street Arboretum Nottingham NG7 4DX Lead Inspector Meryl Bailey Unannounced Inspection 7th April 2009 11:00 Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Mount Vernon Terrace Care Home DS0000002236.V374892.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.V374892.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd December 2008 Brief Description of the Service: Mount Vernon Terrace consists of two large houses in a Victorian terrace in a residential area of Nottingham City. The home is registered to provide care and support for up to 16 people who have a mental disorder (excluding Dementia and Learning Disability). The accommodation spans three floors, (including a basement with a games room and a smoking area.) There is no vertical lift or other adaptations for people with disabilities at the service and because of this the home may not be suitable for people who have mobility difficulties. There are ten single and three double bedrooms available. Only one of these has en suite facilities. 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 weekly accommodation charges are £329.83; the fees do not include cigarettes, hairdressing or chiropody. A copy of the most recent inspection report is available in the home, and the manager told us that people who want to live at the service are given a copy of the service user guide. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people and their views on the service provided. This process considers the providers capacity to meet regulatory requirements and minimum standards of practice and it focuses on aspects of service provision that need further development. We inspected this home six months earlier and found a number of areas of concern that led us to judge the service as providing poor outcomes for people. We have therefore, concentrated on those areas when carrying out this inspection and have not inspected all the key standards this time. We reviewed all of the information we have received about the home since the last report of our key inspection in October 2008. We made an additional visit to the centre in February 2009 to establish if improvements had been made in the handling and administration of medication and we have included the outcome of that visit in this report. We have also included information from the Improvement Plan that was submitted at the end of January 2009 . We ask owners and managers to fill in a questionnaire about how well their service provides for the needs of the people who live there and how they can and intend to improve their service. We received one of these from the manager immediately prior to our visit and provided some useful information. We did the inspection visit with one inspector. It was a short unannounced visit and took place on one day during the daytime. The main method of inspection we use is called case tracking which involves us choosing a sample of people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. We looked at four peoples records and we had some discussions with people within the home. A partial tour of the premises was made of the communal areas and facilities. We also looked at a sample of staff records to find out if checks were carried out before they started working at the home and if they were appropriately trained and supported. What the service does well: People are enabled to make their own choices. They are involved in planning their own support and their plans are reviewed every six months. Encouragement is given to people to attend drop in centres, day trips are provided and leisure activities are provided in the basement of the home. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 6 People had been involved in deciding what was on the main meals menu. People told us, “The dinners are lovely here” and one person said, “I can always choose when I want a meal.” Concerns and complaints are taken seriously and procedures are appropriately followed to keep people safe. Staff are sufficiently trained to support the people living in the home and they demonstrate caring, respectful attitudes. Everyone had the chance to give their views about how they wanted the home to be run at house meetings or individually with the manager. What has improved since the last inspection? What they could do better: There must be an up to date assessment of the needs of any person admitted to the home. This is so that confirmation can be given that the home is able to meet all the person’s needs in respect of health and welfare. The manager should agree an initial individual plan as soon as a person is admitted. This plan should be developed and revised to describe how the current and changing needs, aspirations and goals will be met and achieved. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 7 Clear directions must be given to staff to ensure they offer people their medication on rising as prescribed. This is so that if people are asleep at the time of the breakfast medication round, they will still be offered their morning medication when they are ready to get up for the day. The manager should make sufficient clean medication cups available to ensure all people receive their tablets hygienically. Furniture in the basement should be replaced and the old mattress should be removed in order to make the games area more comfortable for the people using it. The manager should also fit a new television aerial so that people can use the television in the basement. An accurate staffing rota of people working in the home must be maintained in order to give evidence that the home is appropriate staffed at all times. A detailed record must be kept of all food provided. This is in order to demonstrate that a nutritious diet is offered. A record of all visitors to the home must be maintained for the protection of people living there and for the safety of visitors in the event of a fire. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Mount Vernon Terrace Care Home DS0000002236.V374892.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.V374892.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who want to live at the service have their needs assessed before admission and can be assured the service is appropriate to meet their needs, but when assessments are not up to date some needs may not be fully met. EVIDENCE: The manager told us in his Annual Quality Assurance Assessment that he makes sure that people who live at the service have their needs and aspirations “thoroughly” assessed to be sure that these can be met before they come to stay at the home. We looked at assessments for the person most recently admitted and found that it was dated February 2008, but the person did not move into the home until March 2009. There was no care plan for this person and the manager said that he usually writes the care plan within the first six weeks. The manager stated that this person was not receiving medication, but the assessment referred to regular mediction. Hospital admissions were amongst other recent changes that had not been updated on the assessment. However within this assessment and the others we looked at there was sufficient information to establish that needs related to care and mental health and could be met within this home. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are enabled to make their own choices. They are involved in planning their own support, but the absence of an initial plan may lead to support needs not being met. EVIDENCE: We looked at the records for four people and found three of these included plans that gave detail of the help and support needed. As stated earlier the plan for one person admitted within the last two weeks had not yet been devised. Information in the assessment for this person was not up to date. The plan for a person who had lived at the home for more than two years was very clear, giving full detail of social, recreational, emotional and behaviour needs, along with the capacity to make decisions. The person concerned had signed the assessments and plan and there were also six monthly reviews recorded and signed. There was a plan for another person who had been at Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 11 the home for a shorter period of time and this person had not signed it to confirm agreement. The manager had appropriately recorded that the person had capacity to make decisions, but was reluctant to sign anything. The person told us that the support received was as requested. Risks Assessments were included within care plans and a wide range of risks were assessed, which covered various aspects relating to people’s mental and physical health and enabled independence whenever possible. One person told us, “I can go to bed late and get up when I like.” Another said, “I can go out where I like, but I have to tell someone first.” Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 12 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): This is what people staying in this care home experience: 12 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are able to make choices about their life style and recreational activities meet their expectations. Nutritious meals are enjoyed. EVIDENCE: A day trip to Skegness was advertised on the notice board and some people told us they would be going. The manager expected about twelve to go with staff and other staff would stay with those wishing to stay at home. There was a games area in the basement, which was comprised of different rooms. A pool table was used in one room and there was a darts board and television in another. The television was not working as a new aerial was needed, but people told us they could watch television in lounge / dining room. There was also a table tennis table in another basement room, but the manager told us this had not been used for a long time. One other room was painted black and Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 13 an old mattress was stored there. One person liked to spend time in that room for “peace an quiet”. People told us they were pleased with the facilities at the home as they had a choice of what to do and where to spend their time. The manager told us that most people were also members of local drop in centres. We saw people having lunch in the dining room and they were all pleased with the meal provided, which was pie, mashed potatoes, mixed vegetables and gravy, followed by semolina pudding or yoghurt. Two people said, “The dinners are lovely here”. Everyone ate all their meal and took their plates out to a trolley to be washed. One person came into the dining room, but decided not to eat until later, “I’ll have something later. I can always choose when I want a meal.” There were no recent records to show the range of meals that had been prepared, but the manager told us that people had been asked regularly about their meal choices. The care plans included people’s food likes and dislikes (including their cultural preferences). There was also a choice of hot and cold drinks available at all times. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the help with personal and health care that they need, but further improvement is needed with the arrangements for giving medication to promote and maintain people’s health. EVIDENCE: People told us they got up when they liked and did not need help with washing and dressing. We overheard staff appropriately encouraging one person to adjust clothing to improve personal dignity. Needs relating to personal hygiene and continence were addressed in the care plans. We also found clear evidence in the care plans that people have their health care needs assessed. A Community Psychiatric Nurse visited on the day of inspection to treat some people living in the home. There were also records of visits to doctors and hospitals. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 15 At our inspection on 6 October 2008 we were very concerned about medication practice. We set requirements to ensure medication would be handled safely and that there would be accurate records of when people take their medication. We visited on 11 February 2009 and found significant improvements had been made. During the current inspection we again examined the arrangements for handling medication. We saw that a new medication storage cupboard had been purchased, but had not been fixed to the wall and was not yet in use. When ready this will provide more space for the medication. The existing cupboard was kept locked and there were daily temperature readings taken of the area where medication is stored. We checked the records of medication given and found them completed accurately. One person had not received medication at breakfast time due to sleeping, so a code had been entered to show this. However, there was nothing in the person’s care plan or with medication instructions to direct staff to offer the medication later when the person got up. The records showed a regular pattern of the medication not given at breakfast time due to the person being asleep. On most occasions it had later been given and recorded, but not every day and we could see that some tablets were left. The manager told us that staff had attended the Care of Medicines course given by Boots since the last inspection. We watched the staff giving out medication and found their practice had improved during the last six months in that they routinely popped tablets out of the storage packs and into a medication cup before giving to each person. They waited for the person to take the medication and then initialled the record. However, there were insufficient medication cups available and staff had to wash some for immediate reuse. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Concerns and complaints are taken seriously and procedures are appropriately followed to keep people safe. EVIDENCE: We saw that the complaints procedure was displayed in the home. There were no specific complaints about the service, but there was a record of concerns about communal living and the tensions caused by this. The records appropriate action was taken. People told us that they would speak to the manager if they had concerns or complaints about anything. We saw that a copy of the local safeguarding procedures has been obtained since the last key inspection and staff were aware of the procedures to be followed if safeguarding issues come to light. One allegation had been made following an incident at the home and we heard from a social worker that the manager reported this appropriately so that it could be thoroughly investigated. Mount Vernon Terrace Care Home DS0000002236.V374892.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most areas of the home are homely and maintained, with the exception of the basement facilities. EVIDENCE: The home is on four floors. No lift is provided. We saw all communal areas on the ground floor and basement. The ground floor areas were all clean and well furnished. Part of the basement had been redecorated, but other areas needed attention. There were a few old chairs there and an old mattress was the only item of furniture in one room. The television was not working. However, people were happy to have the basement available to them. Attention had been given to the heating and hot water system since the last inspection. We did not see bedrooms during this inspection, but the people we spoke with said they were very satisfied with their own rooms. Some rooms had been redecorated since the last inspection and improvement had been Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 18 made to ensure the second floor bathroom was fully functional and a blind had been fitted at the window. Also, since the last inspection the tumble dryer had received attention and was in full working order. Mount Vernon Terrace Care Home DS0000002236.V374892.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by trained and caring staff. The recruitment practices at the service are safe and protect people from those who may be unsuitable to work with them. EVIDENCE: Since the last inspection staff had received training in Mental Health and the Mental Capacity Act. Two staff had completed National Vocational Qualifications. One of these was Level 3 in Care and the other was at Level 2. The staff files we looked at were well organised and had evidence that all of the information and documentation required had been obtained so that new staff were fully checked before they commenced at the home. We observed staff interacting with people at the home in a respectful way. People told us that they liked the staff and they were “very helpful and fair”. There were a sufficient number of staff on duty, but they were not all the same people that were on the rota for the day as there had been some swapping of shifts (see standard 41). Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all management systems are in place, so the health and wellbeing of the all people living in the home is not ensured. However, checks and staff training ensure that health and safety in the environment are promoted. EVIDENCE: The home is managed by one of the owners of the home. This manager has made some clear improvements during the last six months as can be seen in this report. However, the absence of an up to date assessment and care plan for one person and clear instructions about medication for another shows that further improvements are needed to ensure a good quality of care. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 21 The manager told us that “Resident” meetings were held and everyone had the chance to give their views about how they wanted the home to be run. There had been a positive response to requests for redecorating. People told us that the manager listens to their views. Personal staffing records and records about people living in the home were held securely. As already stated, records for one person were limited to an old assessment. The staffing rota did not reflect the names of staff actually on duty for the week of the inspection. However, people living in the home knew the staff on duty. There were no records of visitors to the home and no recent records of meals provided. The manager told us in his Annual Quality Assurance Assessment that all of the required Health and Safety checks and tests have been done at the required intervals to maintain the health and wellbeing of people living at the service. We found that the Fire Safety tests had been done regularly. All staff had undertaken infection control training. Those preparing meals had received food hygiene training. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X 2 3 X Version 5.2 Page 23 Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement There must be an up to date assessment of the needs of any person admitted to the home. This is so that confirmation can be given that the home is able to meet all the person’s needs in respect of health and welfare. Clear directions must be given to staff to ensure they offer people their medication on rising as prescribed. This is so that if people are asleep at the time of the breakfast medication round, they will still be offered their morning medication when they are ready to get up for the day. Maintain an accurate staffing rota of people working in the home in order to give evidence that the home is appropriate staffed. Keep a detailed record of all food provided. This is in order to demonstrate that a nutritious diet is offered. Maintain a record of all visitors to the home for the protection of people living there and for the safety of visitors in the event of a fire. DS0000002236.V374892.R01.S.doc Timescale for action 30/06/09 2. YA20 13 (2) 30/06/09 3. YA41 17 (2) 30/06/09 4. YA41 17 (2) 30/06/09 5. YA41 17 (2) 30/06/09 Mount Vernon Terrace Care Home Version 5.2 Page 24 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 YA6 Good Practice Recommendations Agree an initial individual plan as soon as a person is admitted. This plan should be developed and revised to describe how the current and changing needs, aspirations and goals will be met and achieved. Make sufficient clean medication cups available to ensure all people receive their tablets hygienically. Replace furniture in the basement and remove the old mattress in order to make the games area more comfortable for the people using it. Fit a new television aerial so that people can use the television in the basement. 2. 3. 4. YA20 YA24 YA24 Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 25 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Mount Vernon Terrace Care Home DS0000002236.V374892.R01.S.doc Version 5.2 Page 26 - 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!