Inspection on 02/08/05 for Mountside Residential Home

This inspection was carried out on 2nd August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Mountside Residential Home 10/12/08

Mountside Residential Home 15/01/07

Mountside Residential Home 15/12/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Mountside 9-11 Laton Road Hastings East Sussex TN34 2ES Lead Inspector Jason Denny Unannounced 2 August 2005 09:45 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 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. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mountside Address 9-11 Laton Road Hastings East Sussex TN34 2ES 01323 646548 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Downlands Care Limited Mrs Freda Steuart-Pownall Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (OP) 43 of places Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is forty-three (43) 2. Service users must be aged sixty-five (65) and over on admission Date of last inspection n/a Brief Description of the Service: Mountside is registered to accommodate forty-three older people. The property is situated in a residential area on the outskirts of Hastings. There is easy access to the town centre and to public transport services. The property is also close to Alexandra park. The home is well maintained and is decorated to a good standard. Accommodation is provided on two floors. There is ample car parking to the front of the property and extensive award winning gardens to the front and rear of the property. The small number of double shared rooms are currently being used as singles unless married couples require them. The home has passenger, in addition to, stair, lifts. The home has recently installed a brand new stair-lift on the advice of an occupational therapist. An additonal stair lift is being planned to support a small number of residents who use rooms on the lower ground floor. Activity provision for service users has repeatedly been found to exceed the normal minimum standard. A number of activity specialists visit the home on a regular basis to deliver a range of activities such as music, singing, art, fitness, and mental stimulation exercises. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced routine inspection [first of two planned before April1st 2006], which took place between 9.45am and 2pm. The Inspection found that of the 17 National Minimum Standards inspected, that 10 of these standards had been fully met, with all others nearly met. The overall focus of the inspection was on how new residents were settling into the home, the quality of staff, care records, and how the home was being managed. The inspector started the inspection by meeting with the manager, reviewing progress since the last inspection and any improvements made since the new owners took over in June 2005. All records relating to staff training, the Rota induction, and recruitment was looked at along with care records. Activities were observed during the visit. A meal was taken in the home followed by with a brief tour of communal areas. Safety documentation was inspected along with resident’s contracts. What the service does well: What has improved since the last inspection? The administration of residents care records has improved by the use of a new easier to follow system. The home has also ensured that sufficient staff are now undertaking National Vocational Training [NVQ] to support them in their Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 6 jobs and eventually meet Government targets. First aid and food hygiene training has occurred for some staff. The new owners were found to be meeting the requirements of a recent Fire service inspection resulting in Improvements to the homes safety. One stair lift has been improved with the installation of a further lift planned to support residents in the lower ground floor area of the home. Written Staff supervision for some has started. The new owners have indicated that they will act on a long standing requirement of recruiting a suitable Assistant Manager to assist the established manager with training and care plan administration of the home and who will work towards the necessary management qualification. The laundry room along with other decoration, and renewal of the home is indicated in the new owners plans for the home. Other staff training is planned, and overall, the impact of the new owners is seen to be positive. Bedrooms and other parts of the home continue to be redecorated where 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. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 & 6 The inspector found that the home provides both prospective and existing residents, with a good level of information although more can be done for the visually impaired. Moreover, the way in which the home assesses prospective or existing residents ensures, that it currently meets needs. Terms and conditions for anyone moving into the home is clearly explained and agreed before someone moves therefore ensuring transparency and accountability. EVIDENCE: A copy of the home’s resident’s [service user] guide including a complaints and suggestions procedure is displayed in the homes reception area with copies given to residents on request. Residents confirmed that they have access to inspection reports, which are discussed at their meetings. The guide also contains a report of resident’s views [last carried out on July 2004], which is, useful for prospective residents to base a judgement upon. Residents and visitors were found to be knowledgeable about their rights. Some of the homes residents have visual impairment or cannot read. The home was again advised to introduce key information on to a talking tape. A number of residents benefit from local and national newspaper being relayed to them by such means. The Inspector found that the home’s assessment information was full, and tallied up with his observations and discussions with individual Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 9 residents. Staff were observed to be particularly mindful of the mobility needs of residents. The inspector found that all newly admitted residents had been assessed by the home’s manager before moving in as confirmed in the dates on records and from discussions. The manager also confirms in writing to relevant people whether or not the home could meet their specific needs. The home was also found to have supported residents to move on when their needs had been assessed to significantly change and could not be safely met by the home. This occurred recently in a case of someone who after being in the home for a short period was referred to a home for dementia. The inspector found written evidence of contracts and terms and conditions being issued to residents on entry into the home. The contract price, including fees, room to be occupied and who pays was found to be entered with the contract signed before or, as the resident moved in. The contract relating to a Resident, who had moved in since the last inspection, was examined. The manager stated that the new owners have brought in new contracts only for future admittances with existing contracts and fees unchanged. These new contracts had the same terms and conditions and fully met the standard. The home continues not to provide intermediate care. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 The home was found to be meeting resident’s health and general needs and was fully aware of what additional support is required. The inspector judged that resident’s rights were upheld. Not all the resident’s needs were set out in the individuals plan of care and in the main the plans lacked detail or evidence of ongoing review. The format of these plans are improved but need to be fully completed in order to measure someone’s full needs, how these will be met, and the success in meeting those needs. EVIDENCE: The Inspector examined 5 care-plans including some of the newest residents and found improvements since the last Inspection with some plans nearly complete. A number of plans were still awaiting comments on history of falls, observations, personal history, activities, routines such as waking up times, and personality. None of the plans examined where found to have had the monthly review sections filled. Those sections of the plans filled in often lacked detail. The original assessments carried out by the manager were more detailed and although they were filed in the care-plan folder their contents had not been fully transferred to the plan of care to show how needs will be met. One care-plan contained clear information on someone’s dietary needs and was also detailed in respect of the persons personal self-care needs. Some Residents preferred waking up times were found to be recorded along with Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 11 hobbies and interests for most Residents. The care plan format was easy to follow and covered a range of areas and are logically laid out. The manager was open and clear about what further work on the care-plans was needed and is working with staff to get them more involved in their review. The appointment of a suitable assistant manager who has paperwork and admin skills was described as necessary to support the administration of the careplanning process. The manager also stated that as a result of staff doing NVQ’s they were becoming more interested in care-planning. A range of health needs such as new residents visual impairment was found to be receiving attention with a eye specialist appointment planned. A new resident confirmed how a particular and personal health need had been met by the home resulting in less pain being experienced. Plans showed where residents had been offered a key to their room with the decision noted. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 Residents are able to make a range of choices about their lives and enjoy an exceptional range of activities provided by the home. Activities are popular with residents especially those organised by specialists who visit the home such as music entertainers and a quizmaster/, fitness coach. Food served by the home was found to be good and popular with residents, and includes an advertised choice between two options. Food is wholesome, balanced and served at flexible times in a nice setting. EVIDENCE: A range of activities are organised to meet the needs of Residents. These include, musical entertainment, pat dog scheme, videos, visiting magician, bingo, card and board games. In addition there is a library provided by the Hastings service, every three weeks, a Communion service every four-weeks, a manicurist every three weeks and a hairdresser provides a service on a weekly basis. The home is licensed to sell alcohol and there is a happy hour one night a week. Newspapers are delivered to the home upon request. A couple of Residents attend clubs once a week. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 13 All activities are on a regular timetabled basis. New activities include in-house art classes, and a motivational class including games and quizzes, and music and dance. This “motivate” session was observed during the inspection where 25 of the 36 residents were seen to participate. All activities were found to be co-ordinated by visiting specialists and occur weekly and regularly. It was also evident since the last inspection, that the home has made a greater attempt to record Residents preferences. As previously reported some care-plans could include more information on people’s interests. A number of residents were observed to relaxing in the extensive gardens at the rear of the property, others were reading newspapers they had ordered. Records indicate the range of choices open to residents such as the choice of a room key. Residents especially praised meal arrangements. The inspector sampled a meal and found it to be good with a range of fresh and tasty ingredients. Four weekly menus were found to be displayed in the home. The manager stated that menus are due for review at the homes annual general meeting where residents are involved in discussing menus. This meeting is being organised for September. Breakfast was found to occur over a 2-3 hour period with most residents still in the process of getting up at their own pace and preferences, from when the inspector arrived at 9.30am. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home operates in an open manner and has not had a formal complaint since 2003 years. Staff continue to demonstrate a sound understanding on how to prevent abuse and continue to benefit from adult protection training. Residents continue to be registered to vote and have all their rights upheld. All residents and visitors are made fully aware of how to complain or raise concerns. EVIDENCE: The manager and one deputy have received formal training in adult protection and prevention of abuse and have delivered this training to all staff. All staff cover prevention of abuse training during their induction. Staff who have been interviewed across several inspections continue to demonstrate a full and sound understanding of all the issues involved, including whistle blowing and who to report concerns too. All residents spoken too confirmed the sensitive care they receive from a long established staff team who were observed by the inspector to operate in an appropriately caring and patient manner. The home has a comprehensive complaint policy and form for reporting concerns. There was no record of any complaint made to the home over the last year. Any concerns are promptly addressed by the manager to avoid issues escalating as confirmed in records and discussions. The home maintains a range of suggestion schemes and meeting forums. Residents were observed by staff to make daily choices such as with wake up times. The last formal complaint raised about the care of residents was in 2003 and related to a misunderstanding about a residents hearing impairment where a staff member was observed to speak in a louder voice in front of a visitor, in order to support a resident. The concern was quickly resolved as seen in records. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The home was found to be clean, warm, and homely and suited to the needs of residents with a range of adaptations in place such as a stair and passenger lift. The home continues to benefit from investment as evidenced in recent works. The large lounge [of two], the dining room, accessible and vast rear garden area are both impressive and especially popular with residents. The rear garden is well maintained by a highly competent gardener. The front garden and flower bed area represent an impressive entrance to the home along with the ample sized car park. Residents enjoy a home, which is spacious, well maintained, and laid out, with more improvements planned. EVIDENCE: The inspector toured communal areas such as the two lounges, some hallways, the dining room and the garden areas. All other areas including bedrooms will be inspected on the next inspection. Those areas looked at were clean and well maintained. Some toilets were looked at and found to be clean and tidy. The home was found to making plans to address recommendations from a Fire service inspection in April 2005 which when fully complete will result in further improvements to the homes safety such as automatically closing doors which are left open to provide good access in the home. Since the last inspection a Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 16 new stair-lift has been repaired and repositioned to made accessibility safer. The new owners are installing a further stair-lift to assist the 3 resident rooms in the lower ground floor. Residents who use these rooms have good mobility with the provision of a stair-lift will reducing the possibility of them moving rooms if their mobility needs increase. Residents and visitors praised the quality and suitability of the building. Those areas of the home inspected were found to be spacious and safe. The laundry area was not inspected and along with future redecoration, is planned for renewal by the new owners of the home. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 30 There continues to be sufficient numbers of suitable staff on duty to meet needs of resident’s along with the cleaning and cooking tasks. These staff are experienced and have worked in the home for a long time. However resident needs and the overall running of the home will benefit with the recruitment of suitable assistant to the manager. Staff training has improved but has further to go to meet the standard but has benefited from better planning and resources. The home is on course to have a sufficiently trained staff team within the next 6-12 months. Residents are protected from harm by sound and tight recruitment practices, which ensure that only suitable people are employed by the home. All residents and visitors praised the quality and stability of the staff team All new care staff receive a full and appropriate induction. EVIDENCE: The home has increased staffing levels since the last 3 inspections with the addition of one extra person on each day shift. The change means one extra person on both the 2pm-8pm and 9am-2pm shift. On the morning shift[9-2pm there is 1 deputy plus 4 staff. On the afternoon shift this is I deputy plus 3 staff. At present there are 36 Residents. The home also employs cleaner’s, cooks, and housekeepers, to ensure that care-staff just focus on residents. Due to the level of work required to monitor care plan’s, staff training and supervision in this large home, it is necessary to provide an additional suitably qualified person to support staff to achieve this requirement. This was made a requirement at the last 3 inspections. It is positively noted that the home showed evidence of actively looking to recruit the right person and stated that an appointment should be made Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 18 shortly. The number of staff studying for NVQ level two has increased from 3 to 12 with some in their final stages. The Inspector was able to see that the home was on course to meet the 50 government target of care staff with this qualification, by December 2005. A number of the staff team have completed Asset courses in care practices and safe handling of medicines. A number of the staff team received training within the last year on diabetes. The inspector sampled the recruitment records of two staff employed as non-care staff since the last inspection. Both staff have had all checks carried out prior to them commencing employment in the home such as completed application form, two suitable references, ID checks, and full Police Criminal records Bureaus checks. One person started before the CRB came back after having a P.O.VA check done [check on a list of those people deemed unsuitable to work with vulnerable people]. The Inspector examined an example of a completed TOPSS Induction workbook for a new member of care staff which had been appropriately filled in by both parties on a gradual basis, and which was proving beneficial. No new care staff have been appointed since the last inspection. The home has an additional in-house induction package in place. Part one is completed as soon as possible after appointment and includes all emergency procedures and part two within the first few weeks of appointment. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,36 & 38 The home continues to benefit from a well-established and motivated manager who has a full range of management skills and understanding of older people. The overall management of the home will benefit from the appointment of a suitable assistant to the manager to assist with administration especially in relation to training, care-planning, and staff support. The home was found to be conducted in an open and friendly manner with staff supported to carry out their roles. The home continues to be popular with residents and visitors. The new owners have had a positive impact and are requested to send the Commission a monthly report on the quality of care being provided as found on their visits and discussions with residents. Residents will be further protected once all staff have completed all the necessary training. Staff and residents will further benefit from all staff receiving formal written supervision on a regular basis to ensure support to perform. Equipment in the home is regularly serviced and maintained to protect residents. Improvements have been made to fire safety practices. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 20 EVIDENCE: The manager has worked in a senior management capacity for a number of years and possesses both Graduate and Professional Nursing qualifications, (SRN, B.Ed(Hons), RNT, Dip Nursing (Lond), relevant to her position. She continues to undertake periodic training courses to update her knowledge and keep her nursing pin active. The manager advised that she continues to carry out regular audits of the kitchen, domestic/cleaning services and the medication procedures. Residents complete questionnaires on their views the last survey being July 2004 with the next planned after the Annual general meeting in September 05. A report and action plan is then published after these surveys. Residents have their own committee meeting which meet two weeks before the AGM to decide the agenda. Staff, management, Residents and relatives attend the AGM. Views on the home continue to be positive. The home has a current development plan, which spans 12 months most of which has been carried out. By the time of the inspection the Commission had not received a monthly section 26 report on the home from the owners for at least 3 months. The new owners only took over 6 weeks before the inspection. A report was received at the Commission’s office on the day of the inspection [which was read at the next time the inspector visited his office], this covered 5 visits to the home between June and July, but these visits did not include interviews with residents in the home, to form a view on the quality of the care provided. The manager has made some progress in ensuring that staff are supervised on a regular basis, and has introduced a suitable format. The manager stated that not all staff have yet received formal written supervision and none are receiving this at least every two months. The inspector sampled records of those staff that had been supervised and found a useful format. Staff were found to be booked on Moving and Handling, food hygiene, and first aid training on courses in August and September 2005 to assist them to meet the safety needs of residents. A high number of established staff were found to have all but the Moving and handling training from a suitable instructor. Record keeping in relation to health and safety documentation was found to be in good order. With portable electrical and boiler tests, along with liability insurance found to be on schedule. The manager stated that she ensures that there is a qualified First Aider on duty at all times. All staff are shown videos in emergency first-aid, moving and handling, and fire, during their inductions whilst they wait for formal courses. All staff recently received training in fire safety. The home was found to be halfway through implementing recommendations from a recent fire service inspection. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 2 x x 2 x 2 Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 7 Regulation 15[1] Requirement That the needs of all necessary service users [Residents] must be reassessed. From the assessments, detailed advice should be included on the level of care to be provided to each service user. Progress with the plans should be monitored and reviewed in line with National Minimum Standards. That the new Care plans are fully completed and include information on service users interests, hobbies, and all other areas as listed in the plans [Requirement of the last 4 inspections. Requirement first made in 2003]. It is required that an additional suitably qualified person must be appointed to assist the manager in addressing the work required to improve the care plans and risk assessments. [Requirement of the last 4 inspections. Requirement first made in 2003]. That the Organisation which owns and manages the home must make arrangements for section 26 monthly visit reports Timescale for action Timescale Extension 02/12/05 2. 27 18[1] Timescale Extension 02/12/05 3. 33 26 02/09/05 Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 23 4. 36 18[2] 5. 38 13[5]& 18[1] carried out by the owner, or their representative, including evidence of named interviews with sufficient numbers of service users[Residents], their representatives, and staff, in order to form an opinion on the quality of care being provided. That this report includes an inspection of the premises and records, with an action plan to show how any shortfalls will be rectified, and by whom. That this report is sent to the Commission without delay on a monthly basis. That all care staff must receive formal supervision at least six times a year. That by the timescale indicated all staff have had a supervision and that further supervisions are booked to occur at least six times yearly. [Requirement of the last 4 inspections. Requirement first made in 2003]. That all staff must have appropriate Moving and Handling training.[Requirement of the last 4 inspections. Requirement first made in 2003]. Timescale Extension 02/12/05 Timescale Extension 02/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 1 28 Good Practice Recommendations That a summary of the Inspection report and other information relevant to service users with a visual impairment is complied onto a talking tape. That the home ensures that it meets the target of at least 50 of its care staff achieving at least NVQ level 2 by April 2005. H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 24 Mountside 3. 31 That the home recruits or puts someone forward to do the NVQ 4 in management and care. Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT National Enquiry Line: 0845 015 0120 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 Mountside H59-H10 S64443 Mountside V237175 020805 Stage 4.doc Version 1.40 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!