Inspection on 26/02/07 for Mountview Residential Home

This inspection was carried out on 26th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Mountview Residential Home 04/10/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Mountview Residential Home Rickmansworth Road Northwood Middlesex HA6 2RD Lead Inspector Ms Pauline Griffin Key Unannounced Inspection 26th February 2007 11:00 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 Residential Home DS0000068739.V328026.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 Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountview Residential Home Address Rickmansworth Road Northwood Middlesex HA6 2RD 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) 01923 824826 Dr Nizar Merali Shiraz Sultan Ali Merali Norma Vidot Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on 28th February 2006, five named service users with a diagnosis of Dementia can be accommodated within the home. This is approved for as long as there is no deterioration of a service user that affects the well-being of any other person living in the home. The rooms used for service users will revert to the listed categories for the home once the service user no longer resides at the home. The home must advise the CSCI when a service user no longer resides at the home. Date of last inspection 17th JULY 2006 Brief Description of the Service: Mountview is a residential care home registered for 12 older people. The building is set back from the Rickmansworth Road in Northwood and is within easy reach of the local shopping centre and public transport links. The premises is a large family home that has been extended and converted to a good standard and offers twelve single rooms, 10 of which have en suite facilities. The large communal lounge is at the rear of the property and a section of this is used as a dining area. Meals are served at two tables set out family style. The rest of the lounge is furnished with comfortable seating, with a television area. The lounge overlooks the garden which can be accessed via french doors from the lounge. The garden is secluded and attractive. Half of the garden is set out in a courtyard style with seating and the other half is laid to lawn with shrubs. The garden can be accessed by people who use a wheelchair. At the front of the property there is off road hard standing parking for several vehicles. The Registered Manager is a Registered Nurse. The staff team consists of a Deputy, 2 Senior Care Worker and seven care workers. The majority of the staff have worked in the home for around 10 years or more. The home is now owned by an organisation who have four Nursing Homes in the local area. This means that it benefits from administrative support provided by the group and also share the services of full time Activities Co-Ordinator. The home also has the services of 2 handymen and a gardener who are employed by the organisation. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out as part of the regulatory process. The inspection took about 6 hours and included a tour of the premises, examination of records and logs, two service user files and two staff files. Service users were observed eating their lunch and the lunch time administration of medication was also observed. The procedures used for safekeeping and recording the administration of medication were inspected. Interviews were carried out with two care workers and the Activities CoOrdinator. Five service users were spoken to during the course of the day. Service users were also observed interacting with the Activities Co-Ordinator and chatting together in the lounge in a pleasant manner. Eight questionnaires were returned to the CSCI from service users or their representative(s) and all spoke positively about the care provided by the staff and the overall service provided by the home. The inspection was assisted by the new Registered Manager who was available throughout the day. What the service does well: The home was owned for many years by the previous proprietors, and the staff team consists of a stable core of care workers who have long service. The new Registered Manager said that she had, therefore, taken trouble to ensure continuity and only made changes where improvement was required. An example of this is in the administration of medication. No complaints had been received and this was a demonstration of how well the change had been managed. The Registered Manager had held a meeting for the service users’ representatives and the minutes indicated that they were able to express any comments they had concerning the changes and comment on the overall level service provided. The atmosphere in the home remains pleasant and the service users were well groomed and well dressed. The five service users spoken to had positive comments to make about the home. Staff were observed to interact well with the service users. The general décor of the home is satisfactory. Repairs are now carried out by either of the two handymen employed by the organisation. A gardener is also employed to maintain the grounds. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 6 The menus of meals are produced over a monthly period. The meals contained a range of traditional food designed to appeal to the service users and included meals like roast dinners, stews and fish and chips. A selection of fresh vegetables and fruit were included in the menus. What has improved since the last inspection? What they could do better: Service users and their representatives have signed contracts with the new organisation who arrange for food to be provided by an Halal supplier. Pork products are, therefore no longer available as part of the service user choice in their menu of foods. The menu is generally well balanced and includes traditional meals suited to the culture of the service users. However, the majority of food offered at supper times is suited to a vegetarian diet and none of the ten service users follow a vegetarian diet. Water temperatures need to be regulated to ensure there is no fluctuation due to changes in water pressure. Staff must have training and update training in mandatory subjects that include areas covered by the Health and Safety at Work Act and the principles of good care practice. Please contact the provider for advice of actions taken in response to this Mountview Residential Home DS0000068739.V328026.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. Mountview Residential Home DS0000068739.V328026.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 Mountview Residential Home DS0000068739.V328026.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, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Service User Guide has been reviewed to include up to date information designed to ensure that service users and prospective service users understand the aims and objectives of the home. New service users are admitted to the home on the basis of a full assessment designed to ensure that the home can meet their assessed needs. Staff have received training in specialist topics that include dementia to ensure that they are trained to meet the care needs of the service users with the condition. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 10 EVIDENCE: Each service user has a copy of the Service User Guide in their room where they are placed in a special Perspex holder. The Service User Guide has been reviewed to include information about the new organisation and it’s aims and objectives. The guide includes the information prescribed in Standard 1.2 of the NMS. The latest CSCI inspection report is kept in the foyer of the home but it was stored in a cabinet. The Registered Manager said that it would be left on display in future. The pre-admission assessment format used by the home is satisfactory. The Registered Manager said that she will assess all prospective service users to ascertain if the home can meet their needs. Five of the ten service users in the home have a diagnosis of dementia. The home has a variation to their registration in order to continue to care for each of these named service users and part of the variation’s conditions is that the CSCI must be informed if any of these five service users leave the home. Several of the staff have attended training in dementia care to enable them to provide appropriate care. Mountview Residential Home DS0000068739.V328026.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most of the service users’ plans have been reviewed to ensure that their care needs are accurately reflected. Service users’ files provided information on their health care and included information regarding medical visits and health monitoring to ensure their health care needs continue to be met. The Registered Manager was able to demonstrate that all aspects of administration of medication were being managed in a safe and satisfactory manner. The staff team are thoroughly familiar with the service user’s needs and were observed to treat them with respect at all times. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 12 EVIDENCE: The Registered Manager said that she has made it a priority to review the service users’ care plans and has almost completed them all. Two plans were examined during the inspection and were found satisfactory. The Registered Manager said that she proposes to carry out monthly reviews with service users to establish their goals and rehabilitation. Service users’ representatives will be encouraged to provide input into the care plans. Each service use’s file now includes a communication sheet to diary events and act as a record of their care. Files included a section on health care and medical appointments. Skin integrity is regularly monitored. None of the service users in the home were suffering from pressure sores. Service user’s records were examined who had continence needs and these were satisfactorily documented. The home has no weighing scales at present and the Registered Manager said that as soon as these had been obtained, she would keeping a record of the service users’ body mass indexes with their weight charts. The home’s administration of medication policy and guidance was examined. Most of the medication is prepared in a pre-dosed blister pack system and other forms of medication are stored in clearly labelled prescription boxes. The pharmacy are placing labels detailing each of the drugs contained in the blister packs on the rear of each one. There are photographs on the individual medication charts and there is a space to register allergies. Six homely remedies have been agreed by the GP’s Only members of staff who have been identified and have received training administer medication. Staff were seen and heard conversing and interacting with service users in a friendly but courteous manner. Service users were well groomed and dressed in well laundered clothes. Service users are always addressed by the name they prefer. Medical examinations take place in the service users’ own bedrooms. Mountview Residential Home DS0000068739.V328026.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): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a structured day designed to suite the needs and wishes of the service user group. The home has an ‘open’ visiting policy designed to be flexible and encourage visits from family and community contacts. The home have advocacy arrangements and keep close contact with the service users’ families to ensure their rights and wishes are represented should they be unable to express their own opinions. Menus are well balanced and provide traditional meals designed appeal to the culture of the service users although no pork products are now included in them. EVIDENCE: Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 14 Service users spoken to said that they enjoyed the activities arranged for them. Friday Bingo sessions are one of their favourites. The inspector observed service users decorating cakes under the supervision of the activities co-ordinator. The activities co-ordinator is a full time employee shared between the five homes in the group. She said that she spends two days at Mountview but also calls in on other days if she is free to do so. The activities co-ordinator spoke enthusiastically about her work and described the subjects she has introduced to the Mountview service users. The programme includes things like painting, craft work, indoor gardening, flower arranging, music, keep fit, pottery, crossword puzzles and quizzes. The home has no set visiting times and encourages contact with the service users’ families and community figures who visit regularly. The home has links with the local church and schools in the area for services, visits and concerts. Some of the service users go out with their families on a regular basis. The Registered Manager said that every effort is made to make visitors welcome in the home. The home also has a link with the Age Concern Advocacy Service and an advocate has visited the service users in the past although no-one has used the service to date. The service users’ bedrooms contain their personal possessions that range from small items of furniture to paintings and photographs. The home is registered under the Data Protection Act 1998 and all personal records are kept in accordance with this. Meals are currently being prepared by two members of the staff team and the kitchen is cleaned by whoever is acting as cook. The kitchen was clean and tidy and there were records of cleaning and logs maintained of the fridge and freezer temperatures. Records are also kept of meals taken by each individual service user. Since the home came under new ownership, the meat is being provided by an Halal supplier and no pork products are available. The Registered Manager said that service users and their representatives were informed of this new arrangement. It was explained to them that if they wished to have bacon, pork or ham, the Registered Manager could buy it for them and cook it but the service user would have to pay for it. The Registered Manager said that either the service users themselves or their representatives had signed a new Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 15 contract that included the new conditions. The new arrangements were also discussed at a meeting held by the Registered Manager with the service users and their representatives and the minutes were examined during the inspection. The subject of food had been discussed at the meeting. During the inspection process concern was received regarding the withdrawal of pork products from the menu. Following the inspection this issue has been discussed with one of the Registered Providers and work is to be carried out to satisfactorily resolve the situation without any additional cost to service users. The menu produced by staff are on a two weekly basis and include a selection of well balanced, traditional meals suited to the culture of the service users. The Registered Manager said that staff discuss the menu with the service users when they make them up. However, it was noted that the majority of the supper dishes were of a vegetarian nature and since none of the service users have a vegetarian diet, this might be reviewed. One of the two staff members who cook the meals in the home is leaving the team and new arrangements will need to be made. All staff who prepare meals and snacks must receive up to date food hygiene training. During the inspection the service users were observed eating their lunch which was roast chicken with fresh vegetables, followed by fruit and gateau. The meal was taken in a relaxed and friendly atmosphere and staff were available to assist where necessary. Mountview Residential Home DS0000068739.V328026.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure is included in the Service User Guide and each service user has a copy of this in their bedroom. The home has a policy on adult protection and the Registered Manager said she will use this in staff supervision to ensure they are familiar with abuse and the different forms it can take. EVIDENCE: The home has a clear complaints procedure which is on display in the home. The complaints procedure is also included in the Service User Guide and the inspector noted that there was a copy in each of the three bedrooms that were viewed. Of the eight questionnaires returned to the CSCI from service users/representative(s), it was noted that all responded to the question of complaints positively, indicating that they were familiar with the procedure and were confident to speak out if there was an issue. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 17 The Registered Manager had a copy of the home’s complaints policy on file. She confirmed that she would obtain a copy of the London Borough of Hillingdon’s Adult Protection Policy to ensure the home is up to date with the Local Authority’s procedures. The Registered Manager said that she would include the subjects of Safeguarding Adults and Whistle Blowing procedures in her one to one supervision meetings with staff. Mountview Residential Home DS0000068739.V328026.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, 24,25 & 26. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home is maintained to a good decorative standard throughout and benefits from the services of two handymen employed by the organisation. Each service user benefits from a comfortable bedroom that includes their own personal possessions and meets their assessed needs. The home is well lit, ventilated and heated. The hot water supply requires attention because it is much hotter than the safety limit of 43 degrees and the home’s records confirm this. The staff team provide cleaning in the home which is hygienic and free from mal odours throughout to ensure a safe and pleasant environment. EVIDENCE: Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 19 The home is maintained to a good decorative order. The Registered Manager has a maintenance file to record things that need attention and aims to produce a cyclical programme. The organisation employs two handymen who can be called on for any emergency repairs and upkeep the decorative order of the home. The grounds are maintained by a gardener who is also employed by the organisation across the five homes. Three of the service users’ bedrooms were visited during the course of this inspection. The rooms contained the service user’s own items of furniture like a comfortable chair or small sofa. It was apparent from the way the rooms were arranged that service users use their bedrooms as a sitting room for the times when they wanted to watch their own television or just sit quietly. Service users rooms also contained their own video tapes, house plants, magazines and selections of their favourite fresh fruits, drinks and sweets. Each room contained a lockable cabinet for valuables. There are no double rooms in the home. The home is well lit, ventilated and maintained at a comfortable heat. Service users’ rooms had their own controls on the radiators. Water in one of the bedrooms was more than hand hot and needs attention. Records are being maintained of water temperatures and these confirmed that the water temperatures are often several degrees higher than the recommended 43 degrees. The water storage was tested for Legionella in February 2007. The home is clean, pleasant and hygienic throughout. The Registered Manager said that there was no designated cleaner and that staff carried out cleaning duties as part of their role. Staff interviewed confirmed this. The laundry was not inspected during this inspection. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team includes an appropriate number and suitably qualified members to meet the needs of the service users. Half the staff team have achieved an NVQ level 2 or 3 and the new Registered Manager is a Registered Nurse. The home has a satisfactory recruitment process based on equal opportunities and designed to protect service users. Staff will have the benefit of accredited training provided by the organisation across the five homes. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 21 EVIDENCE: The staff duty rota was handed to the inspector to examine. The rota included the information that only two staff are on duty from 8am and this frequently included the Registered Manager. It was also noted that the two Senior care workers share the kitchen duty between them for the preparation of the meals each day. Some care workers had shifts for cleaning. There are two staff on duty at night, one waking and one sleeping. Five staff in the home have achieved the NVQ level 2 and 2 have achieved the NVQ level 3. Two staff are studying for the NVQ level 3 and one is studying the NVQ level 2. The Registered Manager is a qualified nurse and will take the part of the Registered Manager’s Certificate that applies to management. The Registered Manager said that she follows sound recruitment practices designed to ensure that service users are protected by thorough vetting procedures. Two staff files were chosen at random and examined. The files were complete with photographs, identity verifications, enhanced CRB clearances, references, employment status and health declarations. The Registered Manager said that she is requesting that all staff have an updated moving and handling training course. She is planning to review the other mandatory training to ensure the whole staff team are suitably trained. Accredited induction training that meets the NTO (National Training Organisation) specification is offered by the organisation across the five homes. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 22 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a qualified nurse and was able to demonstrate her competence at all levels in her ability to manage the home effectively. The Registered Manager has produced a questionnaire format and has set in place other methods of monitoring the quality of the service to the service users. Service users’ monies are managed in a satisfactory manner to ensure their interests are safeguarded. The home has good systems of monitoring and recording and health & safety measures are in place to ensure the safety of both staff and service users. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Manager is a qualified nurse and was able to demonstrate her knowledge and competence at all levels. She is aware of the need to achieve the management equivalent of the NVQ level 4. The Registered Manager has produced a questionnaire for service users and their representative(s) designed to assess the quality of the service provision and people’s views of it. A service users/representative(s) meeting will be held every three months and will be designed to obtain feedback and discuss topical issues. The first meeting of this type was held on 10th February 2007 and the minutes of this were handed to the Inspector for examination. It was noted that topical issues were discussed in this forum. The CSCI received eight questionnaires from the service users or their representative(s). All commented positively regarding the care provided by the staff and the overall service provided by the home. This a measure of the sensitive way the Registered Manager has managed the home’s change of ownership. The individual records of service user’s money was not inspected on this occasion but the arrangements for doing this have not been changed from the way it has been conducted in the past. The home has the benefit of a weekly hairdresser, regular chiropody, newspapers, magazines and toiletries which are charged separately. The Registered Manager said that she wanted to provide each staff member with updated moving and handling training and any other mandatory training that she felt needed being brought up to date. The staff team received training in mandatory subjects at regular intervals from the previous owners of the home but the Registered Manager said that she wished to ensure that all the staff have received the training they need. The Registered Manager has produced a training and development plan to be used as part of the regular staff supervision sessions with staff and this has been designed to identify training needs. A matrix of training courses provided to staff and including dates for review should be produced to provide clear up to date information. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 24 The home has a Health and Safety Policy dated July 2005. The policy includes guidance on preventative measures staff can take and gives a 9 point plan for them to follow. Risk assessments were examined on the service users files and had been satisfactorily carried out. Records of the fire drills carried out in the home were seen for December 2006 and February 2007. The Registered Manager said that fire safety was an area that she intended to ensure staff had up to date training in. Fire alarms are tested each week and records were seen confirming this. The accident book recorded twenty accidents in the past twelve months. Accidents concerned slips and trips and the Registered Manager said she would be making a survey of these to identify the potential of risk in terms of time, person and place. The home still does not have safety mixer valves in place and the water checked by the inspector in the hand basin in bedroom 4 was very hot. Records of the weekly tests showed that the water in the home regularly tested above 43 degrees. The last check recorded the water temperature in room 4 as 50 degrees. The Registered Manager said that a plumber had turned the thermostat down on his last visit in order to reduce the temperature of the water. The water storage was tested for Legionella in February 2007. Mountview Residential Home DS0000068739.V328026.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 X 3 3 X X 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 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 OP15 2 OP25 Standard Regulation 12(4)(b) 16(2)(i) 12(1)(a) 13(4)(a) (c) 18(1)(a) & (c ) Requirement Timescale for action 15/04/07 3 OP30 Service users must be offered a choice of menu in accordance with the traditional food of their culture. Water temperatures must be 02/04/07 restricted to safe limits of around 43 degrees to prevent risk of scalding. Staff should receive training and 15/04/07 update training in mandatory subjects that include areas covered by the Health and Safety at Work Act and the principles of care practice. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 27 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 Refer to Standard OP8 OP15 OP30 Good Practice Recommendations Service users should have their weight monitored as part of a programme to ensure their general health is screened. Supper menus should include a good balance of food that includes meat product choices as well as vegetarian dishes. A training matrix should be produced to provide clear information of the training courses staff have received and when update training is required. Mountview Residential Home DS0000068739.V328026.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Residential Home DS0000068739.V328026.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. Re-publishing this information is in breach of the terms of use of that website. 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