Inspection on 05/07/06 for The Mount

This inspection was carried out on 5th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but 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 15/12/05

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 Mr Keith Jones Key Unannounced Inspection 5 July 2006 9:00 The Mount DS0000028634.V296512.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 The Mount DS0000028634.V296512.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. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Address Wood Lane Yoxall Staffordshire DE13 8PH 01543 472081 F/P 01543 472086 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) Rebecca Homes 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.V296512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 6 LD aged 18 - 65 years on admission. Admission of one named individual over 30 years on admission One service user with diagnosed Mental Disorder with some learning Disabilities. 15th December 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.V296512.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted with the care manager and the full cooperation and contribution of care staff and service users present. There were no outstanding requirements or recommendations. A tour of the home allowed free access to all areas of the Home, and open discussion with those service users present and staff. There were 5 service users in residence, with one out attending college. The other four residents were engaged in general conversation, openly declaring that they were very happy with their Home. Resident’s bedrooms were highly personalised and reflected the personality of the individual occupying the room. There followed a sample review of administrative procedures, practices and records. All service users were case tracked, with four actively engaged in general discussion. Files were accessed to inspect all aspect of their care, from referral to the present time. There followed a report feedback in which the inspector offered an evaluation of the inspection with the Registered Individual and Care Manager designate. Throughout the entire inspection a sense of homeliness and familiar confidence pervaded into all aspects of daily activity expressed by those people met. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: The Mount offers a good standard of care and service, was observed to be well organised, with a committed care manager designate and team. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. The residents spoken with confirmed their pleasure in their daily routine and involvement. Assessment procedures and care planning is of a good standard, offering detailed information on each resident’s progress in the meeting of objectives. The staff and residents all contribute to the team approach. Maintenance of good staffing levels, staff training and supervision are well established in safeguarding the interests of residents. Full attention is paid to the health needs of the service users. Each has a full health audit every six months when the staff talk to them about their physical and mental health and their well being is assessed, with referrals to other health services where required. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 6 Overall the attitude in meeting caring and organisational demands is highly commendable, with a highly personable involvement and application, contributing to a good standard of service. What has improved since the last inspection? What they could do better: Establish a formal annual development plan and present to CSCI at inspections. All service users should be individually risk assessed for kitchen activities, and all risk assessments reviewed three monthly. Cease the practice of institutional notices in personal bedrooms, and in appliances (freezer). Call alarm bells should be working at all times, with breakages repaired immediately. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 7 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.V296512.R01.S.doc Version 5.2 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.V296512.R01.S.doc Version 5.2 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): 1,2,3,4 and 5 Quality in this outcome area is “good”. Prospective residents are assessed prior to admission assuring that the Home can meet their needs. Residents and/or their relatives need to know how they can access the information contained in the Service Users Guide and revised Statement of Purpose. EVIDENCE: During the course of the inspection there was ample opportunity to sit and talk with residents and staff. It was evident that much care had been taken in involving residents and family in the caring process. A resident expressed his pleasure at the relaxed atmosphere, and the general friendliness around. The Statement of Purpose was discussed and found to provide a very informative description of The Mount’s aims, and the way it operated. The contract of residence was presently being updated for all residents, offering clear terms of reference of residence. Examination of resident’s care records and plans clearly demonstrated the extensive efforts to see through the pre-admission and admission procedures and assessments. Each record showed the attention to individuality and their unique needs. Evidence was seen of that assessment process being applied following admission and in continuing care. One resident who had had a difficult period of late expressed his confidence in the quality of care and his much improved relationships in the house. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 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): 6,7,8,9 and 10 Quality in this outcome area is “adequate”. Care planning and risk assessment is comprehensive and covers most areas of the residents’ lives. The residents are enabled to take appropriate risks and have opportunity to discuss any ongoing concerns with staff. EVIDENCE: The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 11 All five resident’s care plans were examined and found to offer an excellent record of daily living, which were comprehensive, and included a provider assessment; a person centred plan, a health and safety assessment, and a planned intervention, rehabilitation and therapeutic programme. Evidence of health care professional visits showed an attentive awareness to service user’s needs. After a protracted absence it was pleasing to see a Social Services input re-established. It was noted that each day had a different schedule of events encouraging therapeutic and social activities geared to meeting service users sense of belonging. Including risk assessment every day activities, although it was advised that a separate kitchen activities risk assessment be completed, and that all risk assessments be reviewed on a three monthly basis. Five residents were case tracked with a full examination of care records, health records including general practitioners and consultant visits, risk assessments, dependency charts, records of reviews and action plans. Records inspected showed that residents are encouraged to make decisions about their life in the home. Residents were seen to be involved in day centre attendances, college, family visits and visits to local amenities. Included in the care records were applications of established monitoring systems following a process of goals, care and evaluation models. Thirteen comment cards were received from relatives, professionals and residents, mostly complementary. The views were shared and discussed with the management, and noted. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 12 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 and 17 Quality in this outcome area is “excellent”. The residents plan their activities together with the staff and individual lifestyles are respected. 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 and improved 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.V296512.R01.S.doc Version 5.2 Page 13 EVIDENCE: The Mount’s main objective is to respect the individual, thus delivering care in a relaxed and easy environment, with routine flexible to accommodate needs, and not dictate daily life of service users. Personal choice and relative selfdetermination are respected in policy and action. Those who wish to bring in personal possessions are encouraged to do so. Activities were in evidence on the inspection day with in-house routines and socialisation. The daily routines involve service users taking part in the up keep of the house. One resident does his own shopping and cooking as part of his independent living programme. Other residents also take part in activities such as food preparation, cleaning and gardening. Choices were available for aspects of daily living, and menus provided a varied and personal choice of food available on a flexible, resident orientated programme. The service users were actively participating in meal preparation activities, including supplying refreshments throughout the inspection. There was a timetable in the kitchen to ensure that all service users had the opportunity to develop their skills in the kitchen. Records show that all staff had a certificate in basic food hygiene. Food cupboards were examined and found to contain varied up to date food stock. Observed practice showed that interaction between staff and residents was friendly and appropriate. Residents confirmed that staff only enter their bedrooms with prior permission and always knock before they enter. A sample of care records demonstrated that residents were encouraged and supported to access a range of leisure and recreational activities, including within the local community. Records showed that participation in socially valued activities was also encouraged. The dining area is homely and friendly within the kitchen area, pleasant, offering conducive ambience for a social meal. The kitchen was seen to be clean, well organised and with modern equipment. An effective cleaning schedule was seen to be in operation. Fridges/freezers and food temperature records were seen to be up to date and accurate. Resident’s life-styles and interests are recorded in their care plans, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. The overall emphasis on the importance of nurturing a solid foundation of trust and respect with the local and wider community is impressive and merits particular recognition. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 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): 19, 20 and 21 Quality in this outcome area is “good”. The health and personal care needs of the residents are clearly identified and monitored. The Home operates an environment conducive in support of individual physical and emotional needs. The routines involving medication was inclusive whenever possible, yet safe, secure and efficiently administered. Staff had a very good understanding of the residents personal, emotional and physical support needs. EVIDENCE: It was pleasing to see that the administration of medicines adhere to procedures to maximise protection to service users, the storage was secure. A suitably qualified member of staff completed MAR sheets accurately, with accountability recorded throughout the process. The system is presently being reviewed. The philosophy of promoting individuality and self-determination, as laid out in the Statement of Purpose, continues to be seen to be exercised in many aspects of care. The general atmosphere throughout the home was one of family, confidence, warmth and contentment. Staff were observed in addressing service users in a respectful and dignified way. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 15 The service user’s spiritual and diverse needs are attended to with respect. Relatives are involved and have free access at all times as desired by the service user. At the time of inspection there were no visitors to speak with. It was noted that an appraisal of any special preferences or observances is recorded on admission, and is regarded as integral in the assessment process. All the residents have a key worker and have individual working records that outline preferred routines, likes and dislikes. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 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): 22 and 23 Quality in this outcome area is “adequate”. The procedures within the Home safeguard the residents and staff. EVIDENCE: Recent complaints and allegations have been handled by the management, through effective policies and procedures, in an effective and thorough manner, concentrating on the meaningful nature of the complaint. It was noted that there have been no requirements made in addressing these issues since the previous care manager left. Allegations of a Vulnerable Adult nature have been dealt with efficiently, with purpose and compassion to meet individual needs. CSCI inspectors have been involved at all stages of the process. The staff have access to the appropriate Protection of Vulnerable Adults procedures and have received training. Criminal Records Bureau and Protection of Vulnerable Adults checks have been made on all staff. Staff are trained in physical intervention techniques, with an emphasis on diversion and distraction and behavioural management plans in place, if required. Behaviours are monitored and evaluated. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 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): 24,25,26,27,28,29 and 30 Quality in this outcome area is “good”. The facilities in the Home are domestic in style and afford the residents with a comfortable, homely environment. Attention is given to ensure a safe, comfortable and secure residence. Bedrooms were well maintained to meet service user’s personal preferences, expressing a highly personal presentation in décor and furnishings. Facilities for toilet and bathrooms are adequate, with up dating presently taking place. Lounges, activity centres and dining rooms were well-appointed and popular areas for socialisation. All areas throughout the Home were clean and hygienically presented. EVIDENCE: The Mount is suitable for it’s stated purpose and provides single bedroom accommodation for each resident. A tour of the Home with the Care Manager allowed free access to all service areas and personal rooms with permission of the resident. During the course of the inspection there was an open exchange with residents on their living domain and facilities available. Five residents are presently living at the home, all bedrooms are personalised and reflect the personality of the individual occupying the room. There are communal lounges and dining/kitchen facilities that are shared by all. The upstairs bathroom has The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 18 new flooring. However the panic alarm bell was broken, and institutional notice should be replaced. The games room is well appointed with facilities and newly acquired ‘massage easy chairs’, and having been newly decorated. The swimming pool is well organised and maintained. There is a strict policy of authorised usage with qualified lifeguard personnel (7 trained or being trained). The kitchen flooring has been recently renewed as part of an ongoing programme of refurbishment. The fridge/freezer has ‘sticky’ labels, which should be removed and replaced with indelible ink instructions. The laundry area was appropriate with good standards, which would be enhanced with more poster-type COSHH notices. Local community facilities are easily accessible and frequently used by residents. The Inspector was impressed with a clean comfortable and odour free environment that residents appeared comfortable in. Individuals had personalised private space as they wished. Planning permission is currently being sought for developing the adjacent stables block as an intermediate living and assessment area for two extra beds. Consequently a development plan for 2006/07 was asked for, with a request for a longer-term plan for 2007/08 to be prepared for the next inspection. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 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): 31, 32, 33, 34, 35, 36 Quality in this outcome area is “adequate”. The residents are protected by safe staff recruitment procedures and supported by a well-trained and supervised staff team. Staffing stability has been achieved and maintained with consistent levels to ensure equilibrium between numbers, skills and qualifications. EVIDENCE: There were 5 service users receiving care at the time of the inspection. Staffing has stabilised following an upheaval after a change in Care Manager. Levels have been maintained with consistent levels to ensure equilibrium between numbers, skills and qualifications. Three weeks of off-duty were examined, providing evidence that the home is suitably staffed in numbers, skills and qualifications to ensure the needs of the service users are met. There are 3 staff in the morning and evening shifts, one night staff with a sleeping carer on duty. Three staff files were examined, identifying a much-improved standard of appointment and personnel management procedures. The Care Manager is presently completing a thorough upgrade of staff administration policies, with the Registered Provider. Records show that the home has a training and development plan for staff. A dedicated training budget is identified in the The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 20 home’s business plan. Staff spoken to confirmed that a detailed and structured induction programme is in place at the commencement of employment. The newly designed induction pack was examined during the inspection, and the registered manager confirmed that all staff are offered a six-week TOPSS certified induction programme. Regular supervision takes place with staff at the home using the opportunity to address their personal and professional concerns with the Care Manager. It was advised that supervision be established on a two-monthly basis. All staff receive training specific to their post, within an impressive arrangement for meeting training needs. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 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): 37,38,39,40,41,42 and 43 Quality in this outcome area is “adequate”. The care manager designate has applied for Commission for Social Care Inspection registration, and has demonstrated a commitment to maintaining the high standards in the Home. All staff demonstrated an awareness of their roles and responsibilities, ensuring that the health, safety, and welfare of residents were observed. Policies are meaningful, supported with up to date procedures and skilled application of good practice. Each presents a safe and secure environment in protection of rights, interests, health and safety of the residents. EVIDENCE: There is a confidence apparent in the interaction of staff and the Home’s management, that demonstrated a positive relationship that pervades throughout the Home. This open style of management was mentioned by several service users, which provided a source of trust and mutual respect. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 22 Quality assurance complements this arrangement with extensive monitoring in areas as care planning, staff meetings, staff training and resident’s suggestions. The case tracking undertaken reinforced the effectiveness of resident’s involvement in their care and environment. A high profile involvement on a daily basis by the Registered provider ensures an ongoing quality appraisal process, dealing with problems as they arise. The financial arrangements were examined and found to be uncluttered in dealing with relatively small sums of resident’s money. The Provider was advised to secure an annual audit of the system and record of accounts. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment. Staff training programmes included relevant aspects of Health and Safety, first aid, moving and handling and fire training were recorded. Servicing records of essential equipment were examined and found to be satisfactory. All accidents and incidents were recorded for staff and service users, including provisions for Riddor should the need arise. It was noted that an extensive review of systems has taken place since the last inspection. The administration and management of the home was seen to be efficient, uncomplicated and sensitive to the needs of service users. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 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 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 2 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 3 3 3 2 3 3 The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA36. 4 18 (2) Regulation Requirement Supervision will be conducted on a two monthly basis for all staff. Timescale for action 01/08/06 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. Refer to Standard YA24 Good Practice Recommendations It is recommended that the home put in place a programme of maintenance and fabric renewal for 2006/07, and prepare a 2007/08 development plan. A Fire report be conducted before submission of variation. It is recommended that a risk assessment is put in place for all residents involving kitchen activities. COSHH notices be in situ in the laundry area. Remove sticky instruction label in the freezer. Repair call alarm in communal upstairs bathroom. It is recommended to submit the resident’s money system to external, annual audit of accounts and procedures. 2 3. 4 5 6 7 YA24 .11 YA20 YA42 .3 YA30 YA29 .2 YA23 6 The Mount DS0000028634.V296512.R01.S.doc Version 5.2 Page 25 8 YA20 It is recommended that risk assessments be reviewed on a three monthly basis. The Mount DS0000028634.V296512.R01.S.doc Version 5.2 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.V296512.R01.S.doc Version 5.2 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!