Inspection on 02/10/06 for Mulroy`s Seaview

This inspection was carried out on 2nd October 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.

Other inspections for this house

Mulroy`s Seaview 13/12/05

Mulroy`s Seaview 15/08/05

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Mulroy`s Seaview 19-22 Newcommen Terrace Redcar TS10 1AU Lead Inspector Jackie Herring Key Unannounced Inspection 3rd October 2006 09:30 X10029.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 Mulroy`s Seaview DS0000055582.V314121.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 and 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. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mulroy`s Seaview Address 19-22 Newcommen Terrace Redcar TS10 1AU 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) 01642 493759 01642 756350 Mr David McArthur Mrs Kay McArthur Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (13) Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 Brief Description of the Service: Mulroys Seaview is a 21-bedded care home providing nursing care to older people and younger adults with mental health problems. The home is a converted property on the seafront at Redcar and close to the town centre, with a wide town centre facilities. All of the rooms are single bedrooms with ensuite facilities, although one room is substantial in size and is being used as a double with the approval of CSCI. The home provides accommodation across three floors, with the younger adults occupying the second floor. The weekly fee is £320. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was completed in twoinspection day, nine inspection hours in total by one inspector. This was to check that the home meets the key standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. There was discussion with three residents and other residents were involved in informal chats. Two staff were interviewed and there was discussion with the manager, deputy manager and one of the qualified nurses. Both direct and indirect observation took place and a range of records were examined including residents files, staff files, policies and procedure, medication systems and maintenance records. The inspector also joined residents for lunch. This was again a very positive inspection and the inspector continues to feel warmly welcomed into the home by all. There was much discussion throughout the inspection, which was very constructive and the manager and deputy positively received any areas identified for further development. What the service does well: Mulroy’s Seaview continues to provide a pleasant, warm, relaxing and welcoming place for the residents. The staff are enthusiastic about working at the home and clearly have very good relationships with the residents and are good at supporting them to meet their needs. Residents said, “I am happy here, this will be the place I will stay until I die, the staff are well mannered and respectful”, “The staff team are very good, there is empathy and understanding”, “This is a safe and happy place to live and I can’t think of anything that isn’t good about it”, another resident said, “Everything is good here, the environment, staff, room, food and I feel safe, supported and cared for”. The environment was also described, as being amongst what was really good, residents said, “My room is ensuite with a shower, it’s really nice”, “I have my own room and it is very comfortable”. The meals were also amongst the really good things and residents said, “The meals vary for every taste and are healthy”. One resident said, “The best thing about being here is that there is a mixture of different people with different identities and needs, all of us are individually catered for”, “I can’t think of anything that isn’t good here, if ever there was, it would soon be rectified”. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 6 The residents also have a good range of activities and recreation, both on an individual basis as well as collectively. What has improved since the last inspection? 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. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 – OP, 2 - YA Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. Resident’s have their needs assessed before they are admitted to the home. EVIDENCE: Five sets of residents’ records were looked at during the inspection, all of which contained assessment information and confirmed that individual needs are assessed prior to admission. Arrangements are in place for residents visit the home on a trial basis. The home is well able to demonstrate it’s capacity to meet the full assessed needs of individual residents admitted to the home. The process for admission to the home is a detailed planned process with significant Multi disciplinary decision-making. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 – OP, 6,8,16,18,19,20 - YA Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. Each resident has a detailed plan of care in place. The assessment records for older people need more work to show that all needs have been considered. Residents need to be consulted and involved in these processes. Medication systems are in the main good although some further development is needed. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 10 EVIDENCE: Five sets of residents’ records were examined during the inspection, three for younger adults and two for older people. They continue to be extremely well written and contained detailed information about the individual residents, their assessed needs and lifestyles. The records detailed involvement of GP, Consultant Psychiatrists, Care Programme Approach reviews and all health related matters. The older people’s assessment records needed some additional development to include risks such as nutrition, moving and handling, skin integrity and falls. Residents need to be involved and consulted with their assessments of needs and care plans, this was not evidenced in any of the files examined although the manager confirmed that it had taken place with some residents. The manager confirmed that they are taking further steps to address this. Residents believed they were treated as individuals and with respect. One resident stated, “the staff are very understanding, they do a good job and are very polite and respectful”. The medication systems were looked at, however could not be fully audited, as the person responsible for the ordering was not available. Of the systems seen, the storage was appropriate, only qualified staff administered medication and the appropriate administration records were in place. It was identified that amendments were needed to the records, such as a photograph for each resident and when handwritten entries are made on the administration records, these are to be signed and witnessed and the directions for as and when required medication needed more information. Consideration should also be given to enable resident’s where appropriate to self medicate. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, 15 – OP 12,13,15,17 - YA Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. Residents are supported to take part in a wide range of activity in the home and further a field. Resident’s dietary needs and choices are well catered for and relatives and friends are encouraged to maintain contact. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents continue to say good things about life within the home and gave examples of how their independence was promoted. A resident said, “There is always a buzz, always something going on, if you want it”, “I make my own decisions about my day to day life, about when I get up and go out”. Staff said of life for the residents, “One of the good things here is that residents independence is encouraged as much as possible”. When talking about activities one resident said, “I enjoy going to keep fit and I also go to a centre once per week, you have freedom”. Another resident said, “I watch TV, DVD’s, set the tables and enjoy going into Town shopping”. Another resident talked about their interest in crafts and said, “I like to do crafts, needlework and tapestry, one of the staff took me out yesterday to buy more craft equipment”. Friends and family are encouraged to visit and one of the resident continues to go home on a regular basis to spend time with his loved one. Staff said that life for the residents in the home was very much about encouraging independence, being supportive and enabling a sociable and meaningful life. Staff spoke with knowledge about individual residents care needs. The manager said that residents meeting had not taken place as frequently as they should have, however this matter was now being attended to. Staff said, “The residents are always given choices, in everything from activities to meals and more besides, there is always plenty going on and everyone can go out of the home”. The resident enjoy their meals, there was a good range of choice and variety and on a variety of different meals were observed over lunchtime, with a very healthy options and fresh vegetables and fruit. One resident said, “The meals are varied for every taste, good variety and healthy, I can make tea and coffee when I want to”. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 OP 22, 23 YA Quality in this outcome area is good. This judgement has been made from evidence gathered before and during a visit to this service. Whilst residents are happy and know what to do in the event of concerns, the actual procedure is in need of updating to ensure EVIDENCE: Complaint records were examined; there have been no complaints since the last inspection. The actual complaints procedure needs reviewing and updating and to include details of the commissioning authorities. Residents are clear about the action they would take in the event they were unhappy or concerned about anything, one resident said, “I have no concerns or worries, I would have no hesitation in raising them and I would rely upon them to do what is necessary and accommodate my wishes”. It was confirmed through discussion with staff and through an examination of their training records that staff had received training in Protection of Vulnerable Adults and No Secrets Training. Residents also discussed the topic of abuse and they confirmed that no such events had taken place within Mulroy’s Seaview. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. Residents live in a homely, well-maintained environment to suit their needs and lifestyles, which is clean and well maintained. EVIDENCE: The environment at Mulroy Seaview continues to be very pleasing, homely and very clean, in which there is a good amount of communal space. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 15 There continues to be space for quiet contemplations as well as areas with music and TV and games/activity areas. On the top floor there was a café area and also a small fully furbished kitchen in which supervised cookery sessions can take place. Residents who were interviewed said that the home was always kept very clean and that it was a very pleasing environment. The residents spoke very positively about their individual bedrooms and said that they had been able to bring their own personal belongings and had been able to choose colours in their rooms. A small number of bedrooms were visited during the inspection, and they were observed to be very individualised, a number of them were locked and it was confirmed that residents had their own keys. One resident said, “I have a nice room and I have seen a nice lilac colour and I might redecorate it next year”. Residents continue to speak very proudly of their home and said, “My room is ensuite with a shower, it’s really nice”, “I have my own room and it is very comfortable”. A spacious yard was available for resident use and contained table and chairs along with parasols. Residents and staff said this are is used during the better weather. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Adequate. This judgement has been made from evidence gathered before and during a visit to this service. The recruitment records do not contain sufficient information to ensure that service users are fully protected, however resident’s benefit from a knowledgeable staff team. EVIDENCE: The manager and staff confirmed that the staffing levels agreed at time of registration were always maintained and regularly exceeded. The inspector was informed that staffing levels continues to be regularly increased depending upon the social, recreational and other needs of the residents. Discussion took place regarding the staffing levels after 6pm as there is a reduction in the number of staff, the manager agreed to review this to ensure that the staffing was appropriate to meet the needs of the residents at this time. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 17 Staff files contained information needed such as references and Criminal Bureau Checks, however the application form did not allow for a full employment history to be written and often these were not accompanied by Curriculum Vitae. In a number of files examined, there was some gaps in the records such as no photographs, no clear evidence of staff member’s identification, such as passport or birth certificate, no statement of terms and conditions, no job descriptions. Checks with the Nursing and Midwifery Council are carried out in respect of qualified nurses. Currently five of the seven care workers have the required National Vocational Qualification, the manager stated that a further two staff were underway with this qualification. Training was also discussed and it was unclear who had received what training, the manager confirmed that he and the deputy were in the process of developing and training matrix and that this would be completed within the next few weeks. Staff said that training such as fire and first aid took place. Staff said that it would be helpful to have more training in respect of the resident’s specific needs. Residents said, “There is a skilled and experienced staff team who definitely have the necessary skills to meet my needs, they are very good”. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 OP, 37,39,42 YA Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. Residents live in a well managed home and well run home, with clear leadership. Whilst residents are happy and safe at Mulroy’s Seaview some of the systems need some additional Staff undergoes some level of supervision, however this frequency needs to be increased. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 19 Seeking of residents’ views and quality assurance is in need of further development as no formal systems are in place. The management of resident personal allowance is good and records are place to safeguard. EVIDENCE: Residents and staff believed that the home is well run and well managed. Resident said that the staff were very understanding, that they do a good job and work very hard. One resident said, “This is a safe and happy place to live and I can’t think of anything that isn’t good about it”, another resident said, “Everything is good here, the environment, staff, room, food and I feel safe, supported and cared for”. Quality assurance was discussed with the manager who confirmed that this was an area that continued to be in need of development. Informal systems such as regular discussion with residents, effectiveness of social activities were described however it was confirmed that no formal systems are currently in place. The system for the management of residents personal allowances was also looked at and found to be a good system with detailed supporting records. Staff supervision was discussed and staff said that this is taking place and records detailing supervisions sessions was made available, however the frequency of these needs to be increased. Fire checks are not being completed on a weekly basis and the manager agreed to take immediate action to address this. A number of fire drills had been carried out and the relevant information was recorded. It was also confirmed by looking at service records that fire and emergency aid training had recently been delivered to the staff by the fire service. A random sample of maintenance and service records were looked at and with the exception of the gas safety certificate all were in order, the manager confirmed that arrangements had been made to have the gas safety check completed within the next two weeks. Policies and procedures were discussed with the manager and although they were in place, it was agreed that they were generally in need of review and updating, as this had not occurred recently. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 20 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 2 37 X 38 2 Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 21 YES 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 OP7 Regulation 13 Requirement Where possible, residents must be consulted about their assessments and care plans and there must be evidence contained within their individual files. (This is outstanding from 01/11/05) The assessments for older people need to include more information and risk assessments such as nutritional, moving and handling and falls. 2. OP9 13 The medication systems must 31/10/06 have some further information, such as individual photographs, handwritten entries must be signed and witnessed and as and when required medication must have the appropriate directions. Staff records must be reviewed 30/11/06 and updated as they do not contain sufficient information, this included the application form as well as records as specified in Schedule 2. Quality assurance systems must 31/01/07 be developed and introduced and DS0000055582.V314121.R01.S.doc Version 5.2 Page 22 Timescale for action 31/12/06 3. OP29 19 4. OP33 24 Mulroy`s Seaview must seek the view of residents. 5. OP38 23 Weekly fire checks must take place. The gas safety certificate must be up to date. The policies and procedures must be reviewed and updated. 31/10/06 6. OP38 23 31/01/07 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 OP9 OP16 OP27 OP30 OP36 Good Practice Recommendations Consideration should be given to enabling residents to self medicate, where appropriate. The complaints procedure should be updated and should include detail of commissioning bodies. Staffing levels should be reviewed after 6pm, ensuring that they are adequate to meet resident’s needs. Training should be clearly recorded and up to date. Staff supervision should take place at the required frequency. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Mulroy`s Seaview DS0000055582.V314121.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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