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Inspection on 12/12/06 for Mountview Community Support Centre

Also see our care home review for Mountview Community Support Centre for more information

This inspection was carried out on 12th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Mountview Community Support Centre offers both short stay and day care. It provides a flexible service, including regular respite care to service users in the area and is the base and contact point for the domiciliary care teams supporting service users in the wider community. Appropriate staff training is provided. Care staff members are knowledgeable about the service users they care for and provide attentive, friendly care and support to meet service users` needs. Mountview receives support from a Specialist Practitioner Nurse from Eastern Cheshire Primary Care Trust on a weekly basis, usually every Tuesday. The input has proved beneficial to both service users and staff and has aided the assessment process and liaison with General Practitioners. The centre is fully adapted to provide care for older service users and domestic staff members ensure that the premises are clean comfortable and welcoming.

What has improved since the last inspection?

The responsibilities of the team managers are being further divided to provide clarity of roles. The part time registered managers now work together for one full week each month to ensure good liaison within the centre, with the staff team and to raise standards. The team managers and care co-ordinator have identified supervisory and key tasks to undertake. The senior support workers also have designated key tasks to undertake and have supervisory responsibilities and the key worker role is becoming more sophisticated. Staff members continue to train to achieve National Vocational Qualifications and senior staff members have been undertaking a modular distance- learning course to obtain a certificate in Safe Handling of Medicines. The Service User Guide was updated in November 2006. A new complaints procedure was introduced in September 2006 to bring about improvements in the management of complaints. Some minor refurbishment work has been undertaken and there are plans to refurbish some of the bathroom areas early in 2007.

What the care home could do better:

The information in the service user guide needs to be adjusted to accurately reflect the level of activity regarding entertainment available in the Centre. Some additional information needs to be added to the statement of purpose. The registered managers plan to undertake unannounced night inspections to offer night staff on waking duty support, and to review procedures and performance. Information in care files needs to be completed more fully and care programmes need to be developed with the minimum of delay. Greater care must be taken when recording medication. The administration and recording of medication must be very regularly and closely monitored to bring about sustained improvement and accuracy. Mountview must ensure that residential service users have access to regular and suitable activities to take part in, as many service users report that there are insufficient activities to occupy them during their stays. Staff members organising activities should receive appropriate training to inform their practice. Efforts to foster community involvement could be made for the benefit of service users and all community involvement could be recorded to inform the next site visit. The recruitment checks and processes could be improved. Also, the management processes of service users money could be improved to protect the financial interests of service users.

CARE HOMES FOR OLDER PEOPLE Mountview Community Support Centre Melton Drive Congleton Cheshire CW12 4YF Lead Inspector Sue Dolley Unannounced Inspection 12th December 2006 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 Mountview Community Support Centre DS0000036720.V317918.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. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountview Community Support Centre Address Melton Drive Congleton Cheshire CW12 4YF 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) 01260 272925 01260 297386 http/www.cheshire.gov.uk Cheshire County Council Susan Ann Bryan Helen Margaret Riley Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (6) of places Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This care home is registered for a maximum of 36 service users to include: * * * Up to 36 service users in the category OP (Old age not falling within any other category) Within the total of 36, up to 5 service users may be in the category PD (Physical disability aged between 55 and 65 years) Within the total of 36, up to 1 service user may be in the category PD (Physical disability aged between 50 and 65 years) 1st August 2006 Date of last inspection Brief Description of the Service: Mountview is a community support centre providing personal care and accommodation, on a short stay/respite basis, for 36 older service users and including up to 5 people with disability aged between, 55 and 64 years and 1 person with a physical disability aged 52 to 53 years. It is owned and managed by Cheshire County Council, which operates a number of similar facilities in Cheshire. The fees at Mountview are based on a financial assessment of the individual. Mountview is in Congleton, close to a small shopping arcade with a variety of shops including two supermarkets, a post office, newsagent, chemist, a bakery and a public house. It opened in August 1988 and consists of a two-storey building. Part of the ground floor has been adapted to provide office accommodation for the home and for the community based services that operate from the building. All the bedrooms are single rooms and have washbasins. Access between the ground and the first floors is via a passenger lift. The garden is accessible to service users. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This second key unannounced visit took place on 12th December 2006 and lasted almost eight hours hours. A Regulatory Inspector had visited on 16th May 2006 to undertake the first key inspection and due to problems with residents’ medicines there was a specialist pharmacist inspection carried out on 1st June 2006. This second key unannounced inspection visit took place to monitor compliance with requirements made at the previous inspections. The visit was just one part of the inspection process. The registered managers were asked to complete a questionnaire to provide up to date information about the services available. Information received since the last site visit was considered. During the visits various records were seen and the premises were looked at. A number of residents were also spoken to and questionnaires were completed with a small number of the residents to find out their views about the care home and about the care provided. What the service does well: What has improved since the last inspection? The responsibilities of the team managers are being further divided to provide clarity of roles. The part time registered managers now work together for one full week each month to ensure good liaison within the centre, with the staff team and to raise standards. The team managers and care co-ordinator have identified supervisory and key tasks to undertake. The senior support workers also have designated key tasks to undertake and have supervisory responsibilities and the key worker role is becoming more sophisticated. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 6 Staff members continue to train to achieve National Vocational Qualifications and senior staff members have been undertaking a modular distance- learning course to obtain a certificate in Safe Handling of Medicines. The Service User Guide was updated in November 2006. A new complaints procedure was introduced in September 2006 to bring about improvements in the management of complaints. Some minor refurbishment work has been undertaken and there are plans to refurbish some of the bathroom areas early in 2007. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some information in the service user guide is inaccurate and could mislead prospective service users. Some information in care files is incomplete and care staff members may not have sufficient information to enable them to care for service users well. EVIDENCE: The Statement of Purpose was updated in January 2006 and is informative. It provides the prospective service users and their supporters with a brief description of the services provided. It contains information about the qualifications and experience of staff and explains the criteria for admission. At present the Statement of Purpose does not contain the telephone number of the complaints officer at County offices, Watling Street, Northwich, Cheshire. In addition, the Commission for Social Care Inspection is referred to only as ‘CSCI’ and readers may not be familiar with the abbreviation. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 9 A Service User Guide was produced in November 2006. It provides a wealth of useful information and is written and presented in a user- friendly format. The section relating to ‘Entertainment’ indicates that there is a comprehensive range of activities available. This does not accurately reflect the very limited level of activity available to short stay service users currently and should be amended until the opportunity for social activity improves. The Statement of Purpose, Service User Guide and the leaflet entitled ‘Getting Things Right’ each provide advice to readers about who to make a complaint to. This information differs in each document and could be confusing to service users and their supporters. Service users needs are assessed before they receive care at the centre. During the site visit, the care folders and care files of three recently admitted service users were checked. The assessment documentation and information contained in the care files was positively written, self -care abilities were described and contact information was provided. Recent social history information was provided and circumstances leading to the placements were well described. Some information was missing from care folders and files. At the time of admission the weight of the three service users had not been recorded. In one file, the functional ability sheet had not been fully completed or dated, the client preference sheet had not been completed, the care plan had not been signed by the service user or team leader or dated. The second file contained comprehensive information about the service user and their circumstances. It included a care programme. This had been signed by the service user, but not by the carer and had not been dated. A third care folder had been compiled in readiness, and awaited information to complete the care programme. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and personal care needs are assessed, addressed and met and service users are referred for medical help as appropriate. The accuracy of medication administration and recording needs to be improved to ensure service users receive their medication as prescribed. EVIDENCE: The care records provided information regarding medical history and ongoing investigations. There was evidence of careful monitoring to ensure service user’s health and personal needs were met. There was evidence of staff promptly seeking medical help and advice to address the existing and changing needs of service users. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 11 A record of health visits is usefully included within the files containing the medication administration records. The record of health visits, include information relating to symptoms and treatment and detail the care -giver responsible. There was evidence of careful monitoring to ensure service user’s health and personal needs were met. Significant event sheets are completed at least twice daily during each planned short stay and the information which they contain enable care staff to provide continuity of care to service users. There was no care programme in place for one service user although the service user had been admitted five days prior. An abbreviation in one file was used, and shown as, ‘VIN’. This was not explained, but used to indicate that the service user had been staying at The Victoria Infirmary. In discussion, some members of staff did not know the meaning of the abbreviation. During the site visit care staff were seen to encourage service users to retain their independence and to support them. Three service users were involved in discussion and were assisted by the inspector to complete questionnaires to establish their views about the quality of care provided. Each reported that the staff members were kindly, friendly and attentive. All three, service users felt that they had been cared for well and said they would return if necessary. They described the care staff members, as polite and said staff members were respectful. The food provided was described as good, varied and plentiful. When asked about the level of activity within the centre, each service user individually said that there was very little to do other than to watch television and converse a little with each other. The observed contacts between service users and staff members were kindly, helpful and reassuring. On 1st August 2006 a Specialist Pharmacist Inspector visited, after the Lead Regulatory Inspector had found some problems with the residents’ medicines. The Specialist Pharmacist Inspector judged that the overall outcome for service users relating to Health and Personal Care was adequate as some residents could be put at risk by staff not managing their medicines properly. A decision was taken to undertake this second key inspection to monitor compliance regarding a number of repeated Requirements made, including a repeated Requirement about medication. At this site visit on 12th December 2006 all the medication administration records were checked. Although a small amount of improvement in the administration and recording of medication was noted, there were many anomalies. To provide an overview of the situation, the medication administration records contained some contradictory information. Some totals of items of medication were not recorded or did not agree with the amount of medication items prescribed. Some creams were not satisfactorily recorded. Items of medication were out of stock. There were unexplained gaps in recording, and some medication was signed as given although it had not been in stock. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 12 Of eight staff who are responsible for medication, five are currently completing a modular distance learning course consisting of five modules and hope to obtain a ‘Certificate in Safe Handling of Medicines’, the three remaining staff members are to be nominated for the same training commencing in 2007. The high level of anomalies found within the administration records indicate an urgent need for very close monitoring, to ensure competence and accuracy and to safeguard service users. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 13 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 and 13 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is only a very limited amount of regular social activity available to occupy short stay service users and only little involvement by local community groups to match service users’ preferences. EVIDENCE: Three short stay service users spoken with, felt that there was a lack of activity and entertainment at Mountview. One of three service users was aware of a limited amount of social activity for some people located on the ground floor and the same person had heard a game of Bingo being played. Two day care assistants are engaged to arrange activities for Day Care service users and other service users receiving a short stay care. Short stay service users were generally unaware of activities taking place. A programme of planned activity was unavailable. The record of activities undertaken was inadequate to evidence what had taken place and how many people had participated. One, day care assistant involved, suggested that she would benefit from some formal training appropriate to her role. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 14 Despite the lack of organised and planned social activity experienced by the short stay service users there was a lively atmosphere within the centre on the day of the site visit and in reception there was an impressive display of Christmas raffle prizes to be won. It is intended that the recently appointed and experienced care co-ordinator will look at the responses from quality standards questionnaires, establish a service user group and explore within the group a range of preferred social activities to be arranged. Although Mountview enjoys occasional visits from the local school and church groups, there was very little evidence of community involvement within the centre and no new community contacts have been made since the last key unannounced inspection in May 2006.One of the part time registered managers envisaged that the care co-ordinator would encourage the involvement of local community groups and/or volunteers within the centre for the benefit of service users. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The action taken as a result of a complaint was not fully recorded to provide a complete audit trail of events. Some staff members need further adult protection training to raise their awareness and to enable them to help protect service users. EVIDENCE: A new complaints procedure was introduced on 1st September 2006 to improve complaints management and in response to consultation in 2002 called, ’Listening to people’. New guidance has been issued to management staff entitled, ‘Learning from Complaints.’ A complaints manager is to be appointed to help effectively manage complaints as part of a county -wide initiative. The pre-inspection questionnaire received, indicated that Mountview had been dealing with one recent complaint. Upon checking, there was no record on file, about the complaint investigation and response. All complaints, and the action taken to investigate and resolve matters must be fully recorded. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 16 Staff members have a basic awareness of Adult Protection and have the Department of Health guidance ‘No Secrets’ to refer to. A whistle blowing policy is available for staff to enable them to respond appropriately to any suspicions or evidence of abuse. The pre inspection questionnaire stated that six members of staff had attended Adult Protection Awareness training within the past 12 months. 12 additional training places have been agreed up to March 2007. The intention is that all care staff will receive this level of training to help raise awareness about Adult Protection. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mountview is clean, decorated and furnished to a good standard which helps to create a comfortable and welcoming environment for the benefit of service users. EVIDENCE: Service users were seen moving freely between their bedrooms and the communal areas. Access for service users between the ground floor and first floor is via passenger lift or stairways. A call alarm system is in place. Service users have comfortable bedrooms and are encouraged to bring in small personal items to make them feel at home during their stay. Ample communal space is provided and lounges are homely and varied in size. Dining areas are attractively presented and there are adjacent satellite kitchens, which are well equipped. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 18 The communal lounge and dining areas and communal bathrooms and toilets were checked during the site visit and all areas were clean, well presented and cared for. Service users confirmed that the premises are always kept clean, pleasant and hygienic. Cheshire County Council has produced policies and procedures for the control of infection to guide staff members in the use of good hygiene practices. Some minor repair and refurbishment work had been undertaken since the site visit in May 2006. The management was advised on of the following matters to be addressed. • • • One bathroom opposite room 19A smelled musty. Wiring was protruding from the wall in a toilet area opposite room 12. A tub of emollient cream, an unidentified cream, a comb and some surgical hand soap had been left in an unattended bathroom. To improve the facilities already provided, work has been planned to refurbish three bathroom areas prior to March 2007. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 19 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): 28 and 29. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff members receive appropriate training to ensure they are confident to perform their care tasks. The recruitment checks need to be more thorough to ensure service users are protected. EVIDENCE: Cheshire County Council are committed to providing training opportunities to ensure staff have the appropriate skills and knowledge to deliver the necessary level of care to service users. The pre inspection questionnaire states that 25 of care staff have achieved NVQ level 2 or above. NVQ training continues to progress for staff who have been registered for NVQ levels 2 and 3. Induction training for new staff members is ongoing. Eight members of staff have been trained to administer medication. In addition to training previously mentioned in this report both team managers and 1 senior member of staff have been undergoing a certificate in infection control. A team manager and a senior member of staff have attended Fire Warden training. Other training has been undertaken regarding maintaining service user records on computer. A range of future training is planned to take place in 2007. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 20 The recruitment files of three new members of staff were checked. The recruitment checks and processes need to be improved as one file contained two references supplied by the same person and the start date of the employment was not indicated. Another file did not contain evidence of a POVA First Check or evidence of a current Criminal Records Bureau check. It would be beneficial to complete a checklist during the recruitment process to ensure all necessary checks are undertaken. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 21 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): 31,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Mountview strives to run in the best interests of service users and promotes and protects their health, safety and welfare. The processes for the management of service users money could be improved to protect the financial interests of service users within the centre. EVIDENCE: Two experienced registered managers share a full time post. This arrangement commenced in September 2005. Work is being undertaken to resolve some management issues and to divide management roles and responsibilities. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 22 This is to avoid duplication of tasks and to ensure all necessary monitoring takes place regularly to support the running of the home and to support care staff. The division of management tasks has yet to be formally agreed by locality manager. Key tasks and supervisory responsibilities are in the process of being divided amongst senior staff, including night care staff. The key worker system is becoming more sophisticated with four groups of staff taking responsibility for 4 groups of rooms. As yet the organisation of activities has not been identified as a key role and the responsibility for medication administration and monitoring medication is to be undertaken by one team manager and the care co-ordinator. From November 2006 the registered managers have planned to work together for one full week a month. This is to ensure good liaison within the centre and with the staff team and to raise standards. The registered managers plan to undertake unannounced night inspections to offer night staff on waking duty support and to review procedures and performance. A form to record these visits has been developed to provide evidence of activity undertaken and findings. Examples of service users’ balances of personal monies held for safekeeping and the related records were checked. These were accurate except that there was no receipt on file for the chiropody treatment of one service user, although an amount of £15.00 had been paid and signed for by two members of staff. Also an amount of £50.00 was recorded and held for safekeeping although the service user had been discharged to another care home three days prior. During the site visit, the premises were checked and health and safety guidance was available to staff. Staff members have been appropriately trained to recognise and report any health and safety issues and have been provided with a pocket guide to health, safety and welfare to inform their practice. Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 2 X X 3 Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 5 and 6 Requirement The registered person must review the written guide to the care home, and where appropriate revise it and notify the Commission of any such revision within 28 days. Timescale for action 31/03/07 2 OP3 14 The registered person must ensure that the needs of the service users have been assessed by a suitably qualified or suitably trained person, there has been appropriate consultation regarding the assessment with the service user or their representatives and, service users’ needs are accurately recorded and kept under review. (This requirement was made at a previous inspection on 16/05/06 and remains unmet). 31/01/07 3 OP9 13 The registered person must make arrangements for the DS0000036720.V317918.R01.S.doc 31/01/07 Version 5.2 Page 25 Mountview Community Support Centre 4 OP12 16 5 OP29 19 recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (This requirement was made at the previous inspections on 30/06/05 and 27/01/06, and remains unmet. The specialist pharmacist inspection of 01/08/06 also found this requirement remaining unmet) The registered person must 31/03/07 consult service users about the programme of activities within the centre, and provide facilities for recreation, having regard to the needs of service users, activities in relation to recreation, fitness and training. (This requirement was made at a previous inspection on 16/05/06 and remains unmet). The registered person must not 31/12/06 employ a person to work at the centre unless they have obtained information and documents specified in paragraphs 1 to 7 of Schedule 2 of The Care Homes Regulations 2001. (This requirement was made at a previous inspection on 16/05/06 and remains unmet). Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP1 OP1 OP3 OP7 OP13 Good Practice Recommendations Ensure that the information in the service user guide regarding entertainment accurately reflects the level of social activity available to short stay service users. Ensure that the advice about ‘Who to Make a Complaint to’ is consistent between the Statement of Purpose, Service User Guide and the leaflet entitled ‘Getting Things Right’. Ensure that the information in the care folders and care files is fully completed. Ensure that care programmes are developed without delay. Consult service users about their social interests, and make arrangements to enable them to engage in local, social and community activities. Encourage involvement in the home by local community groups and/or volunteers to accord with service users preferences. (This recommendation was also made at the previous inspections on 30/06/05, 27/01/06 and 16/05/06 and the situation remains unchanged). Ensure all complaints records contain full information, copies of all communications, evidence of a response to the complainants and details of outcomes. (This recommendation was also made at the previous inspection on 16/05/06 and has not been achieved). Ensure service users’ financial interests are safeguarded. (A similar recommendation was made at the previous inspection on 16/05/06 and has not been achieved). 6. OP16 7. OP35 Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Mountview Community Support Centre DS0000036720.V317918.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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