Inspection on 15/12/05 for The Mount

This inspection was carried out on 15th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mount 10/11/09

The Mount 05/12/08

The Mount 17/04/07

The Mount 05/07/06

The Mount 04/10/05

The Mount 16/11/04

The Mount 22/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Mount Wood Lane Yoxall Staffordshire DE13 8PH Lead Inspector Lorraine Mavengere Announced Inspection 15 December 2005 9:30 The Mount DS0000028634.V278491.R01.S.doc Version 5.1 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 The Mount DS0000028634.V278491.R01.S.doc Version 5.1 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. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Mount Address Wood Lane Yoxall Staffordshire DE13 8PH 01543 472081 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) Mr Graham Howard Cork John Mattew Wade Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (1) of places The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 6 LD aged 18 - 30 years on admission. Admission of one named individual under 18 years on admission Admission of one named individual over 30 years on admission One service user with diagnosed Mental Disorder with some learning Disabilities. 4th October 2005 Date of last inspection Brief Description of the Service: The Mount provides care for five adults with a mild learning disability and challenging behaviour. The home can cater for individuals ranging from 18 to 65 as per assessed need and suitability of placement. The property is a large detached modern house set in extensive grounds in a rural setting close to the small village of Yoxall, near to the town of Burton-onTrent and the city of Lichfield. Service users are admitted on the basis of education and rehabilitation planned towards either independent or semi-independent living. The home provides relevant staffing levels to meet individual needs. Residents are encouraged to fully participate in the daily running of the home, hold their own food budget, to assist in the preparation of meals and housekeeping tasks. The service users are encouraged to choose their own college courses and are supported by staff to access the college. The property is situated close to the local Post Office and shop and is on a main bus route for Burton-On-Trent and Lichfield. The proprietor provides mini bus transport. All residents have their own personal bedrooms and a wide range of leisure activities on site, such as horse riding, swimming, snooker, music and gardening. The home has access to specialist health services such as Psychiatrist/Psychologist and specialist nurses for learning disabilities subject to an appropriate referrals procedure. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 5 The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced. All the service users were at the home during the inspection. The inspector spoke to each one about their experiences of staying at The Mount. Three members of staff were spoken to on this occasion and information was mostly gathered through speaking to the manager, the staff and the service users. Information for the inspection was also gathered through case tracking, reading of records, brief tour of premises and observations. The inspection concentrated on assessing the standards that had not been inspected during the previous inspection. No comment cards regarding the home were received back from The Mount and no relatives were available to be spoken to on this occasion. The home has recently had their certificate of registration amended to allow them to take on an additional service user. The room provided has been approved by CSCI and contains an en suite. This means that the bathroom/ toilet ratio for the other service users is not affected. An additional member of staff will now be used as a result of this. In essence, there will now be one waking night staff and one sleep in staff. The home now has to make sleep in provision. A sleep in room is being constructed next to the office. The registered manager will inform CSCI when this is complete and this will subsequently be followed up by a site visit. What the service does well: What has improved since the last inspection? What they could do better: The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 7 A concern was raised to the Commission for Social Care Inspection with regards to the home. This off set some enquires. It was during these enquires that it was again noted that the individual risk assessments did not cover all areas of individual risk that would safe guard service users. The manager of the home is actively reviewing all the individual risk assessments to ensure the safety and wellbeing of service users. The registered manager must be commended on the urgency in which he has addressed the issues raised both by the enquires to the allegations made as well as by the inspection that subsequently took place. Few areas fell short and requirements have been made accordingly. 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 Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 8 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 The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. These standards were fully assessed during the last inspection with the exception of standard two. The requirements made in relation to standard two have now been fully complied with. EVIDENCE: The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed. These standards were assessed during the last inspection. All the standards were fully met with the exception of standard nine The requirement made for this standard has not yet been met fully and is therefore on going. EVIDENCE: The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Service users are involved in appropriate activities of personal development enabling them to maintain social, emotional, communication and independent living skills. Service users are provided with the opportunity to participate in educational and occupational activities that enable them to maximise their potential and lead a fulfilled life. Service users are well supported to become part of and participate in the local community in accordance with their assessed needs. Service users have access to a range of appropriate leisure activities. There is ample opportunity for service users to have and maintain appropriate relationships. The daily routines of the establishment aim to promote independence, choice and freedom of movement. Meals provided by the home are nutritious, balanced and varied enabling service users’ health to be promoted. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 12 EVIDENCE: Service users spoken to described in detail their personal development activities. It was quite clear from the discussions held that service users are given the opportunity to learn and use practical life skills. One of the service users showed the inspector a rota from which the service users are delegated household chores that enable them to participate in the daily running of the home. The rota included practical life skills such as cleaning, food preparation and laundry. The service users confirmed that this was positive for them and that they felt it helped them achieve the independent living skills that they needed. The registered manager confirmed that two of the residents attend various educational and occupational activities. Two of the residents spoken to confirmed that they attend college. One takes part in a computer and an art class and the other does a hair and beauty course. One of the service users at the Mount chooses not to attend college but partakes in other activities such as football and trips to the town. Another service user does voluntary work at the British Heart Foundation and once a week works with Countryside Services. All service users stated that they were happy with their education and occupation activities. They also said that they felt well supported in finding out what opportunities are available to them. It was evident through discussions with staff and service users that the access that service users have to their local community is very powerful. The service users regularly go out to the pub and engage in other activities such as bowling and go karting. The service users go to the cinema to watch movies of their choice, they access the local gym for exercise and frequently go to the sea life centre and Cadbury’s world. All the residents except one can access public transport independently. The service users’ were able to tell the inspector of their leisure activities. One service user discussed in detail about his interest in video games and chess. He was quite clear in expressing that his hobbies were well supported in the home. Other residents also talked about their leisure interests and hobbies. They confirmed that they choose the organised trips and holidays that they go on. Discussions with service users evidenced that there is ample opportunity for service users to form relationships outside the home and with people who do not have the same disability as they do. Service users spoke of their trips home to their families at weekends and liaisons with friends out of The Mount. The service users’ guide makes it clear that visitors are welcome to the home. The registered manager confirmed that all residents are provided with a set of keys as per risk assessment. The daily routines involve service users taking The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 13 part in the up keep of the house. One service user does his own shopping and cooking as part of his independent living programme. The other service users also take part in activities such as food preparation, cleaning and gardening. Observed practice showed that interaction between staff and service users was friendly and appropriate. Service users confirmed that staff only enter their bedrooms with prior permission and always knock before they enter. Meal preparation time was observed during the inspection. The service users were actively participating in this activity. There was a time table in the kitchen to ensure that all service users had the opportunity to develop their skills in the kitchen. Menu plans were examined during the inspection, these were varied and nutritionally balanced. Records show that all staff have a certificate in basic food hygiene. Service users spoken to confirmed that they could exercise choice where food was concerned. Staff stated that the menu was purely for guidance. One service user said “I can go shopping for food sometimes with staff because we need fresh food you see.” All fridge and freezer temperature records were inspected. These were adequately maintained. Food cupboards were examined and found to contain varied up to date food stock. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20, 21 Staff provide sensitive and flexible personal support in accordance with service users’ needs and preferences. Service users are protected by the home’s policy on medication. The home’s policy on death and dying is very comprehensive and all service users wishes are taken into account. There is consequently clarity as to what needs to be undertaken in the event of death and matters relating to ageing and terminal illness. EVIDENCE: The service users spoken to said they feel the support that they get on a day to day basis is adequate for their needs. Records show that minimal personal care support is required within the service user group as they can take care of most of their own personal care needs. One service user does need more input in the area of personal support but this is documented in her care records and the process for so doing has been assessed and a care plan for this put in place. The manager validated that times for going to bed and getting up as well as meal times are flexible. Service users spoken to state that they can have a lie in on the days that they do not have day time engagements to consider. Service users also confirmed that they choose their own clothes. The The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 15 registered manager verified that additional or specialist support is commissioned as required. Rotas show that there is much consistency in the team and service users benefit from solid continuity. All the residents have a keyworker and have individual working records that outline preferred routines, likes and dislikes. The policy for medication was seen during the inspection. It was robust and comprehensive in nature. All required areas were covered in the policy. Training records show that an adequate number of staff are trained in the administration of medication. The policy outlines that only nominated staff, appropriately trained, may receive, store, dispense or administer medication. The policy also covers refusal by resident to take medication, surplus medication, self medicating and managing errors. The medication cabinet was examined during the inspection. This was seen to be well maintained and tidy. It is recommended that a risk assessment be put in place for the service user who self medicates. At present, the home does not use any refrigerated medicines, nor do any of the service users take controlled drugs. In light of a requirement that was made in the last inspection year, the home have amended the policy on death and dying to incorporate all the relevant items as identified in the standards. Records show that the home now has a comprehensive form detailing all the service users wishes concerning death and dying. The forms have not all been completed. The manager explained that due to the sensitive nature of the enquiries, it is imperative to approach it in an unrushed manner. The forms are therefore being filled out accordingly. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home’s policies and procedures aim to protect service users from potential or actual abuse and act to promote their safety. EVIDENCE: The home’s policies and procedures for managing alleged, suspected or actual abuse are in line with the Staffordshire Interagency Policy on Vulnerable Adult Protection. The policy ensures the safety and protection of service users and is in accordance with the Public Interests Disclosure Act 1998 and Department of Health guidance No Secrets. The training schedule seen during the inspection shows that all staff have undertaken Adult Protection training. This training is also covered in the home’s induction programme. Since the last inspection, one concern regarding adult protection was raised and investigated. The concern was not upheld but the home remain vigilant in ensuring that similar concerns are not raised in the future. The service users spoken to stated that they knew how to report any incidents of abuse and demonstrated that they felt well supported in so doing. There is currently one service user who has limited communication and has more profound learning disabilities than the other residents. Staff spoken to stated that they felt confident that she would be able to notify staff through various behaviours if she was not happy about something. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 On the day of inspection, the home was of good domestic cleanliness and carried no offensive odours. The premises are suitable for their stated purpose and provide adequate living accommodation for the service users. The toilets, bathroom and shower room are sufficient for the number of service users accommodated on the premises. The premises are clean, hygienic and free of offensive odours with some systems in place to prevent the spread of infection. EVIDENCE: A brief tour of the premises showed them to be clean, hygienic, free of offensive odours, tidy and comfortable. The gardens are well maintained and one of the service users helps with this as he has a special interest in gardening. The home is in keeping with the local community and is in keeping with its stated purpose. At the time of inspection, some of the carpets needed either cleaning or replacing. The registered manager stated that this was in line to be carried out. It is recommended that the home put in place a programme of maintenance and renewal for fabric and decoration. The home has changed the registration and can now accommodate an extra resident. This therefore changes the staffing structure. At the time, plans were made available to put in a new sleep in room for the additional member of staff. A The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 18 further site visit will be arranged once the plans have been implemented. The home has a pool area. This is strictly monitored and kept locked to prevent the risk of accidents. The Mount has a satisfactory number of bathrooms and toilets to accommodate the current number of service users in the home. The new bedroom has an en suite therefore the ratio of residents to the bath facilities remains the same. The bathrooms are adequate to meet the service users’ assessed needs and offers them sufficient personal privacy. No bath aids or adaptations are needed by the service users residing at The Mount. A brief tour of the premises evidenced that the home, on the day of inspection, was kept clean, hygienic and free of offensive odours. All staff are trained in Infection Control as part of the home’s mandatory requirements. Records showed that the home holds robust infection control policies and procedures that include safe handling and disposal of clinical waste; dealing with spillages; provision of protective clothing; hand washing. While maintaining its domestic feel, the home has hand- washing facilities sited prominently. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35, 36 The home’s policies on recruitment serve to promote the safety and wellbeing of service users. The registered person ensures that the home’s training programme aims to target the needs of the service users. Service users are well supported by a team of supervised staff. EVIDENCE: Staff files seen show that each member of staff has had a CRB clearance and has two references. The registered manager confirmed that each member of staff is provided with a statement of terms and conditions. These were not seen during the inspection. The registered manager explained that the reason for this is because new contracts had been established and staff were given copies to consider, sign and return to the home. None of the contracts have as yet been returned to the home. The registered manager must ensure that the home keeps copies of all signed statements of terms and conditions. The manager confirmed that all staff are provided with a copy of the General Social Care Council code of conduct. The home’s recruitment policy ensures service users’ safety and wellbeing. The manager also confirmed that all new members of staff are subject to a six- month probationary period. Records show that the home has a training and development plan for staff. A dedicated training budget is identified in the home’s business plan. Staff The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 20 spoken to confirmed that a detailed and structured induction programme is in place at the commencement of employment. The induction pack was examined during the inspection. Although the induction programme is indeed structured and detailed, it does not give room for staff to demonstrate understanding of the content. It is therefore recommended that the induction programme gives staff the opportunity to demonstrate that they understand the content of the induction. The registered manager confirmed that all staff are offered a six week TOPSS certified induction programme. All staff training and development days that are linked to the meeting of the home’s stated purpose are paid for by the organisation. Staff spoken to confirmed that they are entitled to paid training days. The home’s supervision policy was seen during the inspection. The policy states that the purpose of supervision is to identify work issues so as to agree improvement measures thereby ever improving the quality of care. It was pleasing to note that the manager now has a new supervision schedule in place that will ensure that the level of supervision is adequate and at least meets the target of six supervisions a week. This development is as a result of previous requirements made for the home to increase the number of formal supervisions. Staff spoken to confirmed that they were aware of the grievance procedure and had been provided with this at the commencement of their employment. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 42 The home’s quality monitoring systems ensure that service users, staff, relatives and stakeholders views are taken into account. The health, safety and welfare of service users is protected through its safe working practices and policies with some room to improve. EVIDENCE: Records show that there are some quality monitoring systems in place. The regulation 26 visit sheets are routinely sent to the Commission for Social Care Inspection. Records also show that the home carries out monthly audits covering all areas of care, the environment and the staff. The registered manager confirmed that the home has set up questionnaires for service users, relatives and stakeholders. These questionnaires were, however, seen to be inadequate and must be developed to incorporate matters concerning each survey group separately. The results from the surveys must be collated and the information used to plan on areas of improvement. It is recommended that the report feeding back on the results of the survey is made available to all concerned parties. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 22 Training schedules seen show that staff are given safe working training such First Aid, Fire Safety, Health and Safety, Food Hygiene, COSHH and Manual Handling. All the above listed training is mandatory. The induction programme covers all mandatory training. Records show that staff have to undertake an induction programme at the commencement of employment. Besides the in house induction that staff have to do when they first start working for Rebecca Homes, they can also do a TOPSS certified induction and Foundation training programme. The induction programme was seen to be detailed. Fire: The fire records for the home were seen during the inspection. The home has a detailed fire risk assessment. The home has an annual fire inspection and fire fighting equipment service. The fire alarm systems are tested weekly, emergency lighting is tested monthly, fire exits, emergency call points and smoke detectors are also tested weekly. The manager stated that all service users that are new to the home are taken through training of what to do if the fire alarm goes off. Records show that fire drills are carried out regularly throughout the year. Records show that all portable appliances are tested annually by a registered electrician and are next due to be serviced in January 2006. The registered manager confirmed that the home does not use gas therefore does not need a gas safety certificate. Records showed the home to have a comprehensive health and safety risk assessment file that covers all general and environmental areas of assessed risk. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 23 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 N/a 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X 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 3 X 3 3 X X 2 X X 2 X The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 24 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 YA34 Regulation Schedule 2 Requirement The registered manager must ensure that all staff files contain a copy of their statement of terms and conditions. Timescale for action 31/01/06 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. 1. 2. 2. Refer to Standard YA24 YA35 YA20 YA39 Good Practice Recommendations It is recommended that the home put in place a programme of maintenance and fabric renewal. It is recommended that staff are given the opportunity to demonstrate their understanding of the content of the induction. It is recommended that a risk assessment is put in place for the service users who self medicates. 24(1), (2) Questionnaires must be 31/01/06 developed to incorporate matters concerning each survey group separately. 24(1), (2) The results of the survey must 31/01/06 be included in the home’s annual plan and the report made available to all parties DS0000028634.V278491.R01.S.doc Version 5.1 Page 25 3. YA39 The Mount concerned. The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 The Mount DS0000028634.V278491.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!