Inspection on 13/08/07 for Mountford House

This inspection was carried out on 13th August 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mountford House 04/09/06

Mountford House 20/10/05

Mountford House 04/05/05

Mountford House 18/01/05

Mountford House 16/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Mountford House Cyril Road Truro Cornwall TR1 3TB Lead Inspector Mike Dennis Unannounced Inspection 13th August 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountford House Address Cyril Road Truro Cornwall TR1 3TB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01872 274097 01872 223990 mountford.home@cornwallcare.org Cornwall Care Limited Linda Marie Vokins Care Home 37 Category(ies) of Dementia (20), Mental disorder, excluding registration, with number learning disability or dementia (4), Old age, not of places falling within any other category (23), Physical disability (6) Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care - Code PC to service users of either gender whose primary care needs on admssion to the home are within the following categories: Old age, not falling within any other category- Code OP-maximum 23 places Dementia- Code DE-maximum 20 places Physical disability- Code PD- maximum 6 places Mental disorder, excluding learning disability or dementia- Code MDmaximum 4 places The maximum number of service users who can be accommodated is 37. 4th September 2006 2. Date of last inspection Brief Description of the Service: Mountford House is one of eighteen homes owned by Cornwall Care Ltd. It is registered to accommodate thirty-seven older people in need of personal care and who are over retirement age. The Registered Manager is Linda Vokins. Mountford House is a large purpose built care home situated just outside Truro. It is close to local facilities and has good transport links to the local town. Mountford House core services are: - The residential home provides long term care to service users who are in need of personal care and are over retirement age. Mountford House accommodation is essentially on one floor and consists of four wings. Each wing has a its own lounge, bedrooms and bathing facilities. All rooms have call bells. Meals are prepared in a well-equipped kitchen on the lower ground floor and served in a central dining room on the ground floor. All parts of the home are accessible to service users. A patio area at the front is accessible to all who use the home. There is limited parking. The provider gave the charges at August 2007 as from £386 to £490.00. Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a planned unannounced key inspection. The purpose of the inspection was to follow up the provider’s compliance with the requirements and recommendations set in the last inspection report dated 4th. September 2006, and to focus on the key national minimum standards as identified by the commission. The inspector was on the premises for approximately seven hours. The methods used were discussion with the manager, staff, residents, and their relatives and visitors, inspection of records and documents, observation of the daily life of the home and inspection of the premises. The inspector is grateful to the Registered Manager, staff and residents for their assistance in completing the inspection. What the service does well: Service users and their representatives stated that Mountford House provides good quality care and accommodation. Residents made positive statements about the skills and caring qualities of the staff. Residents felt that they could follow their preferred routine and pattern of daily life. They reported that their health needs are monitored and appropriate professional advice and assistance is obtained when necessary. Staff record needs assessments for prospective residents and draw up care plans with the resident and their representatives. There were some good examples of detailed care planning. Residents can take part in a mix of organised group activities and individual activities with staff. Residents felt their visitors were welcomed to the home. Residents and staff felt able to approach the registered manager with any concerns and issues. The home provides homely accessible accommodation mostly on one level. There is a pleasant accessible patio outside. There are a number of staff who have worked at the home for some years. Staff and residents have got to know each other well. Staff receive regular supervision and were satisfied with the support and supervision that they receive. Cornwall Care has a structured training programme and supports and encourages staff in their training and development so that residents and their representatives can have confidence in a well trained and supervised staff team. Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Staff should make a daily record of each resident’s wellbeing, activities and changing care needs, and any events, in order to fully protect their best interests. The provider needs to continue the refurbishment of woodwork and window frames at the rear and sides of the building to ensure that the home is maintained to a good standard. The outstanding areas include a lot of residents’ rooms. The provider should review the fitness of the sluicing facilities, given the increasing level of need of residents accommodated. The provision of a secure garden would greatly enhance the opportunities for residents to be safely outside the building in fine weather Please contact the provider for advice of actions taken in response to this Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 7 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. Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, 6. People who use 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. Prospective residents receive the information they require in order to make an informed choice about residing at Mountford and their needs are assessed so that they can be assured that the home can provide the care required. EVIDENCE: Information is given to prospective residents by of a Statement of Purpose, Service users Guide and brochure. Managers complete needs assessments for prospective residents and obtain assessments from the commissioning authority. Cornwall Care Ltd has a standard format for assessment and care planning which, when completed in Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 10 sufficient detail, covers all the issues specified in the standard. The four residents’ records case tracked in detail contained written needs assessments. Commissioning information from health and adult social care was also on file as were contracts and statements of terms and conditions. Assessments stated who was present, providing evidence that the prospective resident and their family were involved in the assessment. Intermediate care is no longer provided at this home. It has been replaced by a service known as “My Progress”. The object of this service is to keep people in the community whilst meeting their various care needs. On occasion some of these people may be admitted to the home for short time periods. A dedicated team of staff work for My Progress both in the home and in the community. A question has arisen as to whether or not Cornwall Care are registered for this service under their Domiciliary Care Registration. This issue will require further investigation. Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use 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. Residents health, personal and social care needs are set out in individual plans of care which are regularly reviewed and amended. Medication procedures were appropriately followed EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. Staff here also draw up a ‘Care Profile’ - a summary of the care plan used as a working document. All care plans case tracked directed and informed care staff in detail in meeting Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 12 the health, personal and social care needs of residents. These were good examples of individual care planning. The records had evidence of regular reviews. Each resident has a key worker. The Personal Routines and Preferences records detail residents’ lifestyle preferences and choices, their dietary preferences and needs, and their religious beliefs. The level of information in the records is variable. Care staff confirmed that they are involved in the care planning and reviewing residents’ care needs. All residents case tracked had a moving and handling assessment. Falls risk assessments are included as a small part of the moving and handling assessment. Where a resident is at risk of falling, the home completes a separate falls risk assessment to direct staff in reducing the risk and safeguarding the resident. Recent accident records were analysed. There has not been a high level of falls. Care staff do not complete a record every day for each resident. There are significant gaps between entries in the running records. This level of recording does not provide an adequate record of the residents’ wellbeing, activities undertaken, dietary intake, visitors, and other events. Additionally, these records may not reflect all the activities that go on in the home. Staff keep separate records in respect of bathing, and other specific individual health and care needs. Residents are all registered with local GP practices. Residents and their representatives felt that their health care needs were well-monitored and prompt attention obtained when required. Resident records detailed medical contacts for each resident. The community nurses visit the home regularly. It was reported that two residents currently have pressure areas being treated by the community nurses. Residents were very positive about the kindness and caring qualities of the staff. They felt that their privacy and dignity were respected and had confidence in the staff when they were being assisted with care. Relatives and visitors expressed satisfaction with the standard of care provided and the caring qualities of the staff. The Registered Manager monitors staff attention to privacy and dignity by being present around the home and seeking feedback from residents and visitors. The home uses the Boots monitored dosage system. Cornwall Care has a corporate policy and procedure on the handling of medicines which includes guidance on the use of homely remedies. Medicines for the care home are stored in the assistant managers’ office. A locked trolley holds the medicines which are not suitable for including in the monitored dosage system cassettes. Replacement stocks of medicines and the monitored dosage system cassettes are stored in a locked metal cupboard which is secured to the wall. Controlled drugs are stored within this cupboard in a fixed locked container. The Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 13 cupboard and trolley were tidy and well organised. There is a small medicines refrigerator and the temperature is checked daily. Signed consent forms for the administration of medicines were found on each resident’s file. Three residents currently administer their own medication. . Identified staff, who have completed training, have responsibility for the administration of medicines. The administration records in the care home were generally well maintained. Amendments to the records were appropriately referenced, dated and signed. A record of medicines returned to the pharmacist is kept as a duplicate book. The pharmacist had visited recently following the change to the monitored dosage system. Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14, 15 People who use 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. . Residents are supported to follow a lifestyle which accords as far as possible with their own choices and preferences. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: Residents felt that they had control over their daily lives and choices in their routines and patterns of daily living. The home provides some regular programmed activities including games, keep fit, hairdressing and manicure sessions. There are regular religious services and visits from a range of Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 15 denominations. The home shares a people carrier with another home and arranges regular outings. Residents discussed their interests and activities with us. Individual interests are recorded in resident admission information and care plans. The Registered Manager stated that staff look to promote active care, occupation and wellbeing. Residents are supported to continue their own preferred individual activities and interests. Records confirm this although more comprehensive recording will provide stronger evidence. Staff were engaged in various activities with residents during the inspection. There is a flexible visiting policy and residents choose where they meet their guests. Residents felt that their visitors were made welcome. Visitors confirmed that the home’s visiting arrangements suited them. Staff make them welcome and offer them a cup of tea. The Registered Manager stated that she does not act as appointee for any residents for their benefits or manage any savings. Residents’ finances are generally managed with informal assistance from relatives or through Power of Attorney arrangements. Residents can bring in possessions and furniture by agreement with the provider. This was clearly evidenced in some residents’ rooms. Records of furniture brought to the home should be maintained. Cornwall Care Ltd has made available to residents the ‘Care Aware’ advocacy service. The home operates Cornwall Care Ltd’s ‘appetite for life’ initiative to ensure that a varied and appealing diet is provided to residents in a relaxed atmosphere. Breakfast is served flexibly according to individual preferences. The choices include cereal, toast, fruit, prunes, a cooked breakfast and drinks. There are two or three main choices each day at lunch, with further individual choices available. The home is currently providing diabetic diets, and liquidised diets to four people. Residents’ food and drink preferences are recorded. Residents made positive comments about the quality of food provided. They can choose to have their meals in their room or in the dining area. Lunch was a relaxed and sociable occasion with staff providing appropriate support. Residents enjoyed a glass of wine or a non-alcoholic drink with their choice of meal. Hot and cold drinks are served between meals Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use 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. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements to protect service users from abuse. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure which complies with the standard. Mountford House and the commission have not received any complaints since the last inspection. Residents told us that they had not needed to complain, but they were confident that the managers and staff were approachable and would deal with any issues raised. There is a complaints and compliments record. Cornwall Care Ltd has a corporate adult protection policy which includes how to comply with local multi-agency guidance. The manager has a copy of ‘No Secrets’, the Department of Health guidance, and a copy of the Cornwall multiagency adult protection guidance. The manager should ensure that staff are aware of the multi-agency guidance. Cornwall Care Ltd provides training in Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 17 adult protection at induction and during NVQ training. Those staff who have not attended the multi-agency ‘alerter’s’ training, should be considered for this course. Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use 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. The home is generally well presented but some areas require attention to ensure that residents live in a well-maintained environment. Hygiene practices were mostly satisfactory. EVIDENCE: Mountford is a purpose built care home in a residential area close to Truro centre. The main entrance is accessed up a sloped path. There is a moderately sized car park in the rear. The main residential areas of the home are on a single level with the main kitchen, laundry and training rooms on a lower Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 19 ground floor. There is a passenger lift between the floors. The home accommodates residents with mobility difficulties and visual impairments; all areas of the home are accessible to residents. Cornwall Care Ltd has a programme of continuing maintenance. The front aspect of the home has been recently refurbished and is well presented. However, a significant amount of the woodwork and window frames to the rear and sides of the building remain in very poor condition. This is causing problems inside the window frames and sills in some rooms. The communal areas are comfortably furnished and generally decorated to a good standard. The communal areas are generally clean and homely. The dining room is a pleasant shared space with good quality furniture. There is a patio area accessible for residents at the front of the home with seating. The grassed areas to the rear and side have steeply sloping sides and are not accessible or safe for residents. Residents would benefit from the provision of a secure garden. There is a bathroom on each wing. Three have assisted baths; one has a level entry shower. The bathroom facilities were decorated to a good standard and were clean. There are toilets on each wing and these were clean and hygienic. The residents’ rooms are single and four have an en suite facility. Most residents’ rooms were decorated to a good or reasonable standard and were personalised. Some rooms are beginning to need redecoration. All rooms inspected had clean fresh bedding. Residents stated they were ‘happy’ with their accommodation and facilities. Some of the furnishings, both the fitted wardrobes and sink units, and freestanding furniture are showing their age. Odour control was acceptable. Staff reported that there is a maintenance book for logging jobs that need to be done and the general assistant completes these promptly. The laundry complies with the standard. There are two industrial grade washing machines and two tumbler dryers. Staff reported that the equipment was in good working order. Good practice guides are displayed on the wall and COSHH information was available in the office. Soiled laundry is moved to the laundry in sealed bags and there is a laundry chute from the main floor to the laundry. Hand washing facilities are situated around the home with liquid hand wash and disposable towels. There were also supplies of gloves and aprons throughout the home. One of the four sluicing areas has been generally improved to make it easier to keep clean. However, the original aged sluicing toilets and sluicing sinks remain. The wings lack modern enclosed sterilising sluices, which are safe and effective for cleaning the daily high number of commode bowls . Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 20 Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use 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. Recruitment procedures support and protect the service users. Staff are trained and competent to meet the needs of residents. The staffing levels are generally satisfactory. EVIDENCE: Residents commented that they felt staffing levels were sufficient. The roster for the care home detailed five care staff in the morning and four care staff in the afternoon, adequate general assistants and catering staff, and an assistant manager during the waking day. At night there are 2 waking staff and a manager on call. This represents an improvement on staffing levels since the last inspection. The rehabilitation unit is no longer in operation. It has been replaced by a service called “My Progress”. It is aimed at keeping people in the community Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 22 but there are three beds available at Mountford should any people using this service require short term residential care. There is a separate dedicated team of staff to run this service. Cornwall care now employ their own physiotherapist and occupational therapist to support this service. These staff may also assist the people living at Mountford. Posts are advertised through the Job Centre and local press. Cornwall Care Ltd has standard corporate recruitment procedures. Two managers interview applicants using standard set questions. The records of a recently recruited member of staff showed that the required employment checks had been properly completed. Staff records for established staff contained the required documents and information. Staff receive a statement of terms and conditions of employment. Cornwall Care Ltd provides a structured corporate training programme for staff. Training records showed that staff had completed training, or were due to attend required training, in moving and handling, dementia care, food hygiene and health and safety. The provider was engaged in ensuring that all staff had up to date moving and handling. Recently appointed staff had begun their inductions. Staff were satisfied with the training they received to do their jobs. Over 75 staff are qualified to NVQ care level 2. The Cornwall Care Ltd training structure ensures that all new staff are registered promptly for their NVQ level 2. Staff training records were well ordered and up to date. Residents were positive about the skills, kindness and qualities of the staff team. Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. People who use 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. The provider has appointed an experienced and qualified manager who has improved the care delivery to meet the homes stated purpose and objectives. The health and safety of residents and staff is promoted. EVIDENCE: The Registered Manager is Linda Vokins and she was appointed relatively recently. She exceeds the experience requirement for Registered Manager and has an NVQ level 3 plus a Diploma in Management. There are four Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 24 assistant managers. There are clear lines of accountability from the manager through the assistant managers, who each have specific areas of responsibility, and supervise one of the wings and staff. Staff were positive about the support and supervision that they received from the manager. Cornwall Care Ltd has corporate policies for the management of service users’ monies and the home provides safekeeping for small amounts of money. Families and representatives pay in cash on behalf of the residents. Each resident has a record detailing payments in and out, and a running balance. Each resident’s balance is not held as an individual amount of cash – for 40 residents this would amount to a large sum for the home to hold. The cash is held in a specific bank account with a float available for daily transactions. A separate cash book details all payments in and out of the cash float. Proper dated receipts are retained for all transactions on behalf of residents in order to complete the audit trail. This involves, for example retaining a copy of the newspaper bill which details each individual resident’s expenditure. Cornwall Care Ltd has previously sought the views of residents and their representatives, and other stakeholders through questionnaires. The Registered Manager stated that the annual quality assurance survey this year has been completed. Feedback is now imminent following analysis. The staff records showed that all staff receive regular supervision sessions, Staff generally receive annual appraisals. Each assistant manager is responsible for supervising the staff on an identified wing of the home or the night staff team. Staff stated that informal and formal supervision supported them to do their jobs well. Cornwall Care Ltd has comprehensive policies for health and safety. A sample were checked against the original records and found to be accurate. Staff have attended required health and safety training. Staff reported that Cornwall Care Ltd promotes safe working and manages health and safety well. The records showed weekly tests of the fire alarm system and the emergency lighting and regular fire training for daytime staff. There is a written fire plan/procedure. The Registered Manager needs to review if it is the current accurate fire procedure in light of new fire regulations being issued. The home’s fire risk assessment has been completed. The previous report noted some health and safety issues. There was no standard oxygen hazard notice on the door of the garage where oxygen cylinders are stored, although there was a sign warning of the presence of oxygen. Some cupboards required by the fire procedure to be kept locked, were open with keys left in them. The power cables to some pressure mats were not safely stowed but were looped in areas where the resident would be mobilising. All of these issues have been successfully dealt with. Mountford House DS0000009158.V348424.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP26 Good Practice Recommendations The registered person should review the sluice facilities and develop a plan for updating and improving them. Care staff should complete regular daily records for each service user. More comprehensive recording will provide better evidence to support the belief that residents lifestyles mirror their recreational interest and needs. The registered person should review the need for refresher training in adult protection to staff. It is strongly recommended that the registered person DS0000009158.V348424.R01.S.doc Version 5.2 Page 27 2 3 OP7 OP12 4 5 OP18 OP19 Mountford House 6. OP20 must continue the programme of replacing the remaining windows and external woodwork. Residents would benefit from a safe and secure enclosed garden Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Mountford House DS0000009158.V348424.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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