Inspection on 17/01/08 for Mowbray House

This inspection was carried out on 17th January 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mowbray House 16/01/09

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Mowbray House Mowbray House Crook Co Durham DL15 9JG Lead Inspector Karena M.Reed Unannounced Inspection 17th January 2008 1:45pm Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 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 Mowbray House DS0000061977.V343275.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 Adults 18-65. 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. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mowbray House Address Mowbray House Crook Co Durham DL15 9JG 01388 768579 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) deborahbishop@youngfoundations.com Young Foundations Ltd Mrs Deborah Bishop Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (5) of places Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home must only admit service users between the age of 16 - 25 years. 24th January 2007 Date of last inspection Brief Description of the Service: Mowbray House is a large detached house situated in a rural area of Durham. The home is registered to provide personal care to five adults with learning disabilities aged between sixteen and twenty five years. Nursing care is not provided. The accommodation is well decorated and maintained. The house is very close to the town centre of Crook. The home has its own transport. The house itself is a very large building, set in its own spacious grounds. Each person has their own bedroom and they share communal areas, which includes a kitchen/dining room and two lounges. One of the bedrooms on the first floor is a staff bedroom for the member of staff on sleepover duty. Mowbray House is part of the residential services provided by Young Foundations Ltd. The home has an educational facility for any young person who is not attending mainstream school. A Statement of Purpose and service user guide are available at the home for residents who are interested in coming to live at the home. The guides describe the services and facilities provided by the home and how staff are trained to meet service users’ care and support needs. CSCI Inspection reports are also available at the home detailing the quality of care provided by the home. Fees payable for living at the home at the time of inspection in January 2008 are £3750 weekly. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. How the inspection was carried out This is the first inspection of the service since change in registration to a service for adults. We looked at: • • • • • Information we have received since registration of the service in February 2007. How the service dealt with any complaints and concerns since its change in registration. Any changes to how the home is run. The provider’s view of how well they care for people. The views of people who use the service and their relatives, staff and other professionals. The visit • An unannounced visit was made on January 17th 2008 During the visit we: • • • • • Talked with people who use the service, relatives, staff, the person in charge and visitors. Looked at information about the people who use the service and how well their needs are met. Looked at other records that must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. We told the provider what we found. 4 surveys were sent to people who use the service, 2 were returned. 6 surveys were sent to care professionals and relatives, 2 were returned. Comments include: Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 6 “There is no doubt that there are some staff members who are very caring and committed.” “We have regular phone contact with our relative.” “The house furnishings etc are of a very high standard.” “Food seems to be of a good standard.” “I would like more positive information to be shared and not just when things go wrong. Although the teacher does give me regular reports now ” “More 1:1 time at weekends.” “I would like more information as to what my relative does out of school hours and at weekends.” “ I feel that there seems to be fairly frequent change in staff.” What the service does well: What has improved since the last inspection? Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 7 This is the first inspection of the service since change in registration from a children’s home. What they could do better: Information should be made more accessible to people who use the service to help them in decision-making. Care plans must be used as tools and broken down to show the amount of support that should be provided by staff to help the person who uses the service achieve their assessed goals. Carpets in bedrooms must be cleaned in the interests of health and safety. Privacy screening should be provided in the side bedroom overlooked by houses. The wall in the dining area must be repaired. The kitchen cupboards without handles must be repaired. Staffing levels must be increased to ensure that one member of staff is not left to care for a resident, run the house, cook and attend to administration due to the needs of people who use the service. A policy must be devised for the use of the monitor/alarm in order to protect the privacy and dignity of people who use the service. The Admission/Discharge book must contain details of any person who uses the service over night stay away from the home. The personal allowance record requires two signatures when dealing with the money of people who use the service. Staff meetings should be held more regularly. The keys for the medication cabinet must be kept on the person. Any staff who administer medication must receive safe handling of medication training. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 8 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. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4. People who use the service experience good quality in this outcome area. We have made this judgement using a range of evidence including a visit to this service. Information is available to give to prospective residents before they move in to help them decide if they want to live at the home. The home collects enough information about the needs of prospective residents before they move in to help ensure staff are aware of the amount of care and support needs of the resident as they settle in. Staff receive training to give them the knowledge and insight to help understand the needs of residents and to provide the necessary levels of care and support. Residents and their relatives are very welcome to visit the home to assess its suitability. EVIDENCE: The Home’s Statement of Purpose and service user guide were examined, they contained the necessary information as required by the Care Homes Regulations 2001, but they were not easy to read. The service user guide could Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 11 be made more easy to read maybe in a format using symbols and pictures rather than just the written word, so some residents may more easily understand them. A virtual tour of the home can be made on the Organization’s web site to get more information about the home and see some aspects of it. Records for three residents showed that when they were admitted to the home an assessment of their care needs had been carried out before their admission. The resident and relevant people who knew them were involved in the initial assessment. The assessment form encourages staff to explore issues relating to equality and diversity as it refers to gender, cultural, religious/spirituality, educational and social histories, preferred daily routine and preferences. It also looks at mood, speech, behaviour, mental health, risks, sexuality and living skills. This information and the care manager’s assessment of the resident’s care needs were used to ensure all the needs of the resident could be met by staff. The records contained a range of information. The information was not transferred into care plans to help any new staff provide the correct amount of care and support to the people who use the service. Staff receive training so that they know how to meet the needs of the residents. Staff have received the necessary statutory training: Fire Training, Food Hygiene, First Aid, Protection of Vulnerable Adults and National Vocational Qualifications. Staff have also received training about; infection control, risk assessment, challenging behaviour, working with learning disabilities. The manager had identified a skills audit was required to ensure staff had the necessary training to help them meet the needs of the people who use the service. Residents have the opportunity to visit the home as often as they need in order to decide if they want to live there. A resident may come for meals, have overnight stays and be introduced to other residents at the home at a pace suitable to the individual. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 People who use the service experience adequate quality in this outcome area. We have made this judgement using a range of evidence including a visit to this service. There are quite good arrangements in place to ensure that residents’ health and social care needs are met. There is a system of reviewing the changing care needs of residents. Residents are encouraged to be involved in decision-making and to communicate and make their views known. Staff support residents to take risks as part of independent living. Information about residents is handled appropriately, and their confidences are kept. EVIDENCE: Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 13 There are detailed assessments in the residents’ care records. Care and support needs are not documented in the form of care plans to give instructions to staff on how to support people that require support with tasks and carrying out any assessed tasks to help promote the independence of the person. Care plans are not in place although residents care needs are reviewed six monthly or earlier if required if a resident’s care and support needs change. Residents care records showed that they have access to external health care services. GPs, Psychiatrist and Community Psychiatric Nurses were regularly consulted for advice and treatment. Records show residents are assisted to access chiropody, dental and optical services at least annually or as often as required. Residents are asked individually and consulted about decisions involving themselves and the running of the home. Residents choose the colour scheme for their bedroom. The home supports residents to remain independent and take risks in order to live a more fulfilled lifestyle and up to date risk assessments were present in residents care records. Residents care records contained statements of confidentiality to remind staff what information could or could not be disclosed about residents. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 People who use the service experience good quality in this outcome area. We have made this judgement using a range of evidence including a visit to this service. Residents are encouraged to take part in age, peer and culturally appropriate activities. Residents are part of the local community. Residents enjoy appropriate leisure activities. Residents are encouraged to have appropriate personal, family and sexual relationships. Residents’ rights and responsibilities are recognised in their daily lives. Residents are offered a healthy diet. EVIDENCE: Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 15 Observation between residents and staff showed that residents are involved in making decisions about their life. Residents’ records showed that they are consulted and asked their opinion and encouraged to make decisions. Conversation with a resident and staff showed staff support residents to acquire skills and become more self sufficient in aspects of every day living. Some residents may attend day care services and College. A teacher works at the home providing education to some residents but she is currently on maternity leave. Residents all pursue their own individual hobbies and interests, some enjoy shopping, discos, walking, watching videos and DVDs, football, trampolining, computing, skittles, cinema, museum and theatre trips. They also enjoy meals out. Some residents may also visit the local leisure centre for swimming and snoezellen. The home has transport so residents enjoy trips to Theme Parks, Metro Centre, the coast and other places of interest to them. Residents are supported to holiday in this country or abroad. This year some residents have enjoyed individual holidays with the support of staff to Scarborough staying in a caravan. Within the home residents bedrooms can be equipped with their own music centres, books and pictures and whatever is of interest to the resident, this is also dependent upon their needs. Residents’ care records detail any family involvement. Conversation with staff provided evidence that residents are encouraged to maintain contact with family and friends, staff providing the necessary levels of support for them to do so. Residents are asked individually what they wish to eat and a menu is devised. A light snack is available at lunch times and a cooked meal is served in the evening. On the day of inspection residents were being served salad and beef burgers and Angel Delight for tea. Residents may some times eat out. Residents do not have access to the kitchen without the support of staff. Residents enjoy cooking and baking with staff support. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19.20 People who use the service experience adequate quality in this outcome area. We have made this judgement using a range of evidence including a visit to this service. Residents may receive personal support in the way they require. There are arrangements in place to ensure that service users’ health care needs are met. Systems are in place for residents to retain and administer their own medication where appropriate. EVIDENCE: Three case records were inspected. The daily records did provide some detail about the care and support required for different needs but this was not in sufficient detail to ensure consistency amongst all staff especially with the high dependency needs of the residents. There were no care plans in place to accurately record the actual care and support provided by staff to people who use the service. Long term staff would know the amount of care and support to Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 17 provide to residents but new staff and agency staff would not have this knowledge with the absence of care plans. Records showed when residents had seen health professionals e.g. doctors, community nurses, psychiatrist and psychologist. Records also showed when residents had seen opticians and dentists. No resident administers their own medication currently. A system could be put into place to oversee the medication of residents if they should retain and administer their own medication in the future. The keys for the medication cabinet were left in an accessible location rather than being kept on the person. Only staff who have received the safe handling of medication training can administer medication to residents. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality in this outcome area. We have made this judgement using a range of evidence including a visit to this service. The complaints procedure is available so residents and their relatives can bring any matters of concern to staff or people outside of the home. Residents are protected from abuse. EVIDENCE: There is a complaints procedure if complainants are not happy with the homes investigation and response. Residents are reminded of their right to complain.. The home keeps a record of complaints. Ten complaints have been received by the service in the last year and they have been satisfactorily resolved. As part of staff induction staff receive training about the rights of people with learning disabilities. New staff complete the LDAF Course, Learning Disability Award Framework. Staff have received training about Protection of Vulnerable Adults and Prevention of Abuse. As the service provided care to children who have now become adults staff have also received training about Child Protection. Arrangements are in place for new staff members to receive this training about Protection of Vulnerable Adults. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 19 Staff have received training about working with behaviour that may be challenging. Due to the type of service provided staff have received training about the use of restraint. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,30 People who use the service experience good quality in this outcome area. We have made this judgement using a range of evidence including a visit to this service. Residents live in quite a homely, comfortable and safe environment. Residents’ bedrooms are comfortable and some reflect their interests. There is a good standard of hygiene around the home. EVIDENCE: The house is large and comfortable and there is some programme of redecoration and improvement around the home. Bedrooms are quite comfortable and well furnished and personalized according to the interests and wishes of the residents. Some residents spend time in Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 21 their bedrooms listening to music and relaxing as well as spending time with other residents and staff in the communal areas. The home is clean, well decorated and well maintained apart from: there was a large hole in the wall in the dining area. Some bedroom carpets were dirty and stained in places. Some of the kitchen cupboards and drawers had broken or no handles. One bedroom to the side of the house was overlooked by a neighbouring property and this would give no privacy to the resident when his curtains were open. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 People who use the service experience adequate quality in this outcome area. We have made this judgement using a range of evidence including a visit to this service. The numbers and skill mix of staff meets residents’ needs most of the time. Systems are in place to ensure residents are in safe hands. Residents are protected by the home’s recruitment policy and practices. Staff are trained to meet the care needs of residents. A system of supervision is in place to support the staff. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 23 EVIDENCE: Examination of staff rotas and discussion with the person in charge and members of the staff team showed that the numbers of staff are as follows: 8.00 am- 8.00pm 5.00 pm-9.00pm 9.00pm-9. 00 am 3 staff 2 staff to following day 2 waking staff. These numbers include the manager. Staffing levels are increased to four staff members if five residents are in the house. The staffing roster is flexible depending upon the activities of resident, residents often enjoy one to one support with staff for swimming, personal shopping or other activities. Most residents require 1:1 attention at all time of the day in the house. On the day of inspection two staff members were required to escort residents from college and day care services they were away over two hours due to the distance of the services from the home, this left one member of staff to provide 1:1 support to a resident, cook tea, attend to a person who called to mend the fire alarm and assist with the inspection. Another person was available in the office but they were not on the roster or able to provide assistance with care and they went off duty and the existing member of staff was left on their own for at least an hour. The staff group is balanced providing both male and female workers to work with residents. Staff stated that they enjoyed working in the home and were observed to be kind, caring and respectful to residents. Staff receive LDAF Learning Disability Award Framework as part of their induction. Over 50 of the staff team have achieved or are working towards a National Vocational Qualification at level 3. Staff and their records showed that they also receive advice and /or training in other areas. Staff have received training in Equality and Diversity, Dysphasia, Autism, Protection of Vulnerable adults, Infection Control, risk assessment, challenging behaviour, working with learning disabilities, epilepsy awareness and health training. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 24 Staff usually receive regular supervision four – six weekly from the person in charge but this has not been carried out recently due to staff absences. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 People who use the service experience adequate quality in this outcome area. We have made this judgement using a range of evidence including a visit to this service. Residents’ benefit from a well run home. Residents and staff benefit from the ethos, leadership and management approach of the home. There is a regular system to review the quality of care provided by the home. Most of service users’ rights are safeguarded and protected by the home’s policies and procedures. There is quite a good standard of record keeping. The health, safety and welfare of residents are promoted and protected. Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 26 EVIDENCE: The manager, Deborah Bishop is registered as manager for the home, she has several years experience and has the necessary qualifications. Due to some of the health care needs of residents’ listening monitors have to be used in bedrooms to ensure their safety, this is intrusive, a policy was not available to inform staff of when they could be used and when not to be in order to provide some privacy and dignity to residents and at the same time ensure their safety. Documents detailing fire safety, risk assessments in the environment, water temperatures, financial records and statutory records were all up to date apart from: the daily register did not record any overnight absences of residents from the home. The health and safety of residents was protected as far as possible apart from the medication keys were kept in an accessible place in the office and were not kept locked up or on the person. Staff must not administer medication to residents unless they have received safe handling of medication training. Residents personal allowance records did not contain two signatures when staff were dealing with their monies. Staff meetings and residents meetings are held quite regularly but minutes were not available since July of 2007. . Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 3 3 3 3 3 3 2 x Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 28 N/A 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 Standard YA6 Regulation Requirement Timescale for action 30/04/08 2 YA18 3 YA24 4 5. YA30 YA33 6 YA40 7 YA41 15(1)(2)(a)(b)(c)(d) Care plans must be formed for each resident describing the care and support required by staff and how residents are to be assisted to achieve prescribed goals. 13(1)(6)(7) Care plans must include the behavioural needs and interventions required to support residents. 23(2)(b) The identified wall must be repaired. Kitchen drawers and cupboard handles must be replaced. 23(2)(d) The identified bedroom carpets must be cleaned and made good. 18(1)(a) Staffing levels must be reviewed to ensure the safety of residents and staff at all times. 12(4)(a) A policy must be made available for the use of the listening monitor to protect the privacy and dignity of residents as well as their safety. Schedule 3 The admission/discharge 17(3)(e) book must record any DS0000061977.V343275.R01.S.doc 30/03/08 30/03/08 28/02/08 30/03/08 29/02/08 29/02/08 Mowbray House Version 5.2 Page 29 8. YA42 13(4)© overnight absences of residents from the home. Keys for the medication cabinet must be kept locked up or on the person. Staff must receive safe handling of medication training before they can administer medication to residents. 29/02/08 9 YA42 18©(i) 29/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA7 Good Practice Recommendations Information such as service user guide, complaints procedure, menus, care plans should be made available in formats other than the written word in order to help residents be involved in decision making and retain more control in their daily living. Privacy screening should be provided to the overlooked bedroom window in order to protect then privacy of the resident. More regular staff and resident meetings should take place. Resident personal allowance records should contain two signatures when dealing with resident monies. 2. YA26 3. 4 YA38 YA41 Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Mowbray House DS0000061977.V343275.R01.S.doc Version 5.2 Page 31 - 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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