CARE HOME ADULTS 18-65
Thomas Edward Mitton House Belvoir Avenue Emerson Valley Milton Keynes Bucks MK4 2JA Lead Inspector
Christine Sidwell Unannounced Inspection 28th February 2008 10:30 Thomas Edward Mitton House DS0000015072.V359505.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 Thomas Edward Mitton House DS0000015072.V359505.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. Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Thomas Edward Mitton House Address Belvoir Avenue Emerson Valley Milton Keynes Bucks MK4 2JA 01908 504778 01908 505103 tem@birt.co.uk 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) The Disabilities Trust Dr Rashmi Sharma Care Home 16 Category(ies) of Physical disability (0) registration, with number of places Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Physical disability (PD). The maximum number of service users to be accommodated is 16. Date of last inspection 8th December 2006 Brief Description of the Service: Thomas Edward Mitton House is a 16-bedded, single storey, purpose built residential home for people with a physical disability, arising from an acquired brain injury. The aim of the unit is to provide specialist rehabilitation for people with brain injury, to enable them to become independent or to move to residential or community services which can meet their needs. The accommodation consists of 16 single rooms, which are all en-suite. The house has a library and a large dining area, as well as therapy rooms and lounges. There is a conservatory and gardens. Thomas Edward Mitton House is well located to take advantage of the facilities in Milton Keynes, with the public transport service running close by. The current weekly charges range from £1849.00-£2635.00. Additional charges are made for hairdressing, newspapers and toiletries. The home has a statement of purpose, service user’s guide and brochure which gives detailed information about the home and which can be obtained from them. Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes.
The inspection took place over three days and included a five hour unannounced visit to the home. Prior to visit the manager was asked to complete an annual quality assurance self-assessment, which she did and returned on time. Information received by the Commission for Social Care Inspection since the last inspection was considered in the planning of this inspection. Prior to the inspection questionnaires were sent to the manager to distribute to service users, their families and staff. The service users, the manager and staff were spoken to on the day of the unannounced visit. Records were examined and a tour of the building undertaken. The way in which the organisation promotes equality and diversity was considered throughout. What the service does well:
Resident’s rehabilitation needs and wishes are thoroughly assessed before they move to ensure that the service can meet them and that service users will benefit from the rehabilitation service offered. There is a comprehensive multi professional assessment, which includes service users, their families and reflects service user’s aspirations and goals. Any potential restrictions on individual’s choice, freedom, services or facilities are discussed with the service user and his/her representative and recorded in the plan. There are detailed rehabilitation and support plans in place, which describe service users’ needs and how these are to be met, within a risk assessment framework. Service users and their families have been involved in developing these support plans, which reflect their goals and wishes. Service users are supported to achieve their rehabilitation goals and to relearn and undertake activities, which may be risky to them, due to their cognitive damage. Service users are supported to have a varied and active lifestyle, which reflects their interests and abilities. They are encouraged and supported to remain in contact with their families and to continue with their education to support their goals and progression to independent or supported living. Service users’ personal, psychological, healthcare and medication needs are met in a flexible, supportive way to maximise their ability to meet their own personal rehabilitation goals. The complaints and protection policies and procedures work well, giving residents, and their families, confidence that their concerns will be addressed and any safeguarding issues will be addressed, in conjunction with the local
Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 6 authority. The Commission for Social Care Inspection has been notified of one complaint and one safeguarding allegation since the last inspection. The home is clean and comfortable and the appropriate facilities are provided for service users with complex needs to pursue their rehabilitation goals. Service users are encouraged to personalise their rooms. There is a range of adaptations and specialist equipment available to support service users in their rehabilitation. Staffing levels are good and there is a qualified multidisciplinary team in place to support service users to meet their rehabilitation goals. There is a high level of therapeutic input from clinical psychologists and therapists who are based in the home. The rehabilitation support workers have specialist brain injury training although more should be encouraged to achieve the National Vocational Qualifications in Care at level 2. Staffing levels are good which means that service users receive high levels of individualised support. The home is well managed in the interests of service users. There are good quality assurance systems in place to ensure that the care and service is of a consistently good standard and that the best outcome for service users is achieved. The manager is a qualified clinical psychologist. She has recognised that in the home’s plans for the future improvements she should undertake the National Vocational Qualifications in Management at level 4 or equivalent management qualification. The Disability trust has good quality monitoring arrangements in place to ensure that standards remain high. There are health and safety policies and procedures in place to protect service users and staff. Maintenance records and safety checks are undertaken regularly. It is recommended that the manager review the operation of the service’s health and safety procedures in line with guidance published by the Health and Safety Executive entitled ‘Health and Safety in Care Homes’, to ensure that she is fully up to date and that they comply with the guidance. Further information can be obtained from their website www.hse.gov.uk. What has improved since the last inspection?
The service user’s guide has been updated and additional information about advocacy services in the area has been displayed in the home. The process of goal setting with service users has been reviewed and goals have been broken down to into short and long-term gaols, which may be more meaningful for service users. Medication management has improved. The home has introduced a process whereby service users can be assessed as to their ability to learn to self-medicate and a structured programme to support them in doing this has been introduced. There have been ongoing improvements to the fabric of the home. A new washing machine with a sluice cycle has been bought and a smoking shelter erected on the patio.
Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Thomas Edward Mitton House DS0000015072.V359505.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 Thomas Edward Mitton House DS0000015072.V359505.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s rehabilitation needs and wishes are thoroughly assessed before they move to ensure that the service can meet them and that service users will benefit from the rehabilitation service offered. EVIDENCE: The care of two service users was looked at in detail. A clinical psychologist had assessed both prior to their move to the service, either at home or in the place in which they were currently staying. There were copies of the referrals and assessments made by other health and social care professionals in their files. A comprehensive assessment was undertaken, which includes assessing the service user’s individual needs arising from their disability and their cultural and religious wishes. The manager also said that prospective service users would be invited to visit the service following the initial assessment and an ongoing assessment of their rehabilitation goals would be undertaken. Service users and their families would be involved throughout. A rehabilitation plan had been developed and any potential restrictions on individual’s choice, freedom, services or facilities were discussed with the service user and his/her representative and recorded in the plan. Thomas Edward Mitton House DS0000015072.V359505.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are detailed rehabilitation and support plans in place, which describe service users’ needs and how these are to be met, within a risk assessment framework. Service users and their families have been involved in developing these care plans which reflect their goals and wishes. EVIDENCE: The care plans examined described service user’s goals and the planned actions and interventions to meet them. Long-term goals were broken down into achievable short-term goals. The rehabilitation and support plans were clear and comprehensive and set out how identified needs should be met. Guidelines on how staff should be providing positive re-enforcement were detailed in care plans seen. The plans had been evaluated and reviewed regularly with service users, their families and other social and healthcare professionals. Detailed risk assessments and weekly activity sheets were in place, which were tailor made to meet the needs of individuals. It was evident that the Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 11 care plans were working documents and staff spoken to were familiar with the contents. The staff were observed to respect service users’ wishes. They said that wherever possible service users are encouraged and helped to regain control of their lives and to make informed decisions. A range of options were provided to support service users to reach their rehabilitation goals, including cookery groups, social outings, shopping trips, leisure trips and pub lunches. Service users were planting seeds for the garden on the day of the unannounced visit to the service. One resident particularly wished to go shopping and she was assisted to do so. The staff said that whenever possible service users are supported and encouraged to manage their own finances for as long as they are able to. The home manages small amounts of personal allowance for some service users and the appropriate records and receipts are kept. Risk taking is identified during the assessment process. Risk management is an essential part of the treatment plan and staff were aware of the need to manage potential risk whilst supporting service users to achieve their personal goals. The staffing levels are such that there are sufficient staff to work with service users to help them undertake every day activities of living such as preparing meals and going out, within the risk assessment framework agreed for each individual. Risk assessments were reviewed every three months or as and when needed. The home has policies and procedures in place to respond to any unexplained absences. Thomas Edward Mitton House DS0000015072.V359505.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to have a varied and active lifestyle, which reflects their interests and abilities. They are encouraged and supported to remain in contact with their families and to continue with their education to support their goals and progression to independent or supported living. EVIDENCE: The home has a vocational trainer who supports service users to continue with their education and to develop new skills. Service users’ views are sought when planning the routines of daily living and arranging activities both in and outside the home. Each service user has an individualised daily programme, which is established during their initial assessment and is reviewed regularly. The daily plan includes supporting service users to participate in community life. Staff support service users whose behaviour may make this difficult and see it is part of their work to influence local community members to understand the effects that brain injury may have on people’s behaviour. Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 13 Staff respect service users’ rights and privacy and were seen knocking on their bedroom doors and waiting for a reply before entering. Throughout the inspection staff were observed speaking to service users sensitively and addressing them by their preferred choice of name. Staff support individuals to prepare meals, look after their personal laundry or to use the social facilities in the local community, as part of their rehabilitation programme. There was evidence in care plans seen that service users were encouraged by staff to maintain family links and personal relationships. Lunch was observed and was a relaxing and social occasion. It was noted that all staff on duty including the chef participated in the lunchtime activity and joined service users for lunch. Those service users who needed assistance with feeding were provided with assistance sensitively and at their own pace. Tables were covered with tablecloths and the appropriate crockery and cutlery were provided to promote independence. Service users said that the meals were always prepared to a high standard and an alternative choice would be provided if they did not like what was on the menu. The menu is varied and included fresh fruit and vegetables. Thomas Edward Mitton House DS0000015072.V359505.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users’ personal, psychological, healthcare and medication needs are met in a flexible, supportive way to maximise their ability to meet their own personal rehabilitation goals. EVIDENCE: The high ratio of staff to service users means that individual support can be given to service users to enable them to do as much as possible for themselves. There are male and female rehabilitation assistants so that a carer of the same sex can give care if a service user wishes. Service users were wearing their own clothes. Service users had technical aids to assist them when necessary. One service user was using a computerised communication aid. Others had specially adapted wheelchairs. There was evidence in the support plans that service users had access to the full range of local primary and secondary healthcare facilities and that their health was monitored and problems acted upon. There are medication management policies and procedures in place and the staff spoken to were aware of these. Storage facilities are satisfactory. Records are kept of medication entering and leaving the home. The medication administration records were accurately completed. Controlled
Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 15 drugs were stored satisfactorily and all entries to the controlled drug register were signed. A contract is held for the disposal of unused medication. The staff spoken to said that medication was not administered covertly. If a service user refused medication this would be recorded. If the medication was essential and the resident lacked the capacity to make to the decision, the doctor and family would be informed and a way forward agreed. There is a staged system in place to help service users develop the skills to manage their own medication as part of their rehabilitation. One service user was at the stage where he was encouraged to say when his medication was due and staff then got it out for him. He had an hours grace around the due time and if he had not remembered he was then reminded. Records were kept to measure his progress. Thomas Edward Mitton House DS0000015072.V359505.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints and protection policies and procedures work well, giving residents, and their families, confidence that their concerns will be addressed and any safeguarding issues will be addressed, in conjunction with the local authority. EVIDENCE: There are complaints policies and procedures in place. The manager said that she records both verbal and written complaints. The manager said that there had been five complaints since the last inspection all of which had been resolved within the organisations timescales. Records were seen to confirm this and also to show that action had been taken to address them. Three service users returned the questionnaires and all said that they knew who to speak to if they were unhappy. The home has an up to date copy of the local multi-agency strategy for safeguarding vulnerable adults. Most staff have had safeguarding training and those spoken to said that they would have no hesitation in reporting any concerns about resident’s welfare. There are whistle blowing policies and procedures in place. The home has made six referrals to the local authority safeguarding teams since the last inspection. Records were seen to confirm that the appropriate action had been taken. The Commission for Social Care Inspection has been notified of one complaint and one safeguarding allegation since the last inspection. Thomas Edward Mitton House DS0000015072.V359505.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable and the appropriate facilities are provided for service users with complex needs to pursue their rehabilitation goals. EVIDENCE: Thomas Edward Mitten House is purpose built and is on one floor. There are wide spacious corridors and doorways to allow for wheelchair access. The gardens are accessible and there is a courtyard, with a shelter should service users wish to smoke. Bedrooms have ensuite facilities and most service users had personalised their rooms to make them feel more homely. There are adapted baths and showers. There is a kitchenette where service users can prepare meals, under supervision, as part of their rehabilitation programme and a gym. The communal lounge is small and the manager said that it was difficult to accommodate all service users, particularly if they had a wheelchair She has plans to reorganise the internal communal accommodation within the home to address this. The standards of infection control are good. There are policies and procedures in place, which have been updated in line with the Department of Health’s
Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 18 guidance issued in June 2006. Staff were observed to be wearing protective clothing and were observed to wash their hands and had had training in infection control. Alcohol hand rub is available to help prevent cross infection. All residents have their own hoist slings where they require assistance. The laundry is well managed and the home was clean and tidy on the day of the unannounced visit. There were no offensive odours. Thomas Edward Mitton House DS0000015072.V359505.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels are good and there is a qualified multidisciplinary team in place to support service users to meet their rehabilitation goals. EVIDENCE: There is a qualified staff team which includes, clinical psychologists, occupational and speech and language therapists and a physiotherapist. There is a vocational trainer. The head of care is a qualified nurse. The manager stated in the annual quality assurance questionnaire that two of the rehabilitation support assistants held the National Vocational Qualifications at level 2 or above and on the unannounced visit confirmed that a further 16 had registered for the course. The service does not yet meet the standard that 50 of support staff hold this qualification. The manager said that staff were enthusiastic but that sometimes it was difficult to release them. Rehabilitation support staff undertake the Brain Injury Rehabilitation Trust (BIRT) basic and intermediate neurobehavioral course to help them understand the physical and behavioural challenges that people with brain injury may experience. The staffing levels are good and the staff team reflect the gender of the service users. There are regular clinical staff meetings although these did to always include the head of care. Rehabilitation support workers who acted as key workers were not usually invited to the service users review meetings although
Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 20 the manager said that their observations would be taken into account. Most rehabilitation support workers spoken to said that they felt part of the team although one felt that they should be involved more. One clinical team member also echoed this view. The recruitment files of three recently recruited members of staff were reviewed. All had the required documentation to show that checks as to the potential staff member’s identity and suitability to work with vulnerable people had been undertaken. All had submitted an application from, which showed their work history. Interview records had been kept. Two references had been sought and Criminal Records Bureau checks had been undertaken before the staff member commenced work. There was evidence in the files seen that work permits had been obtained where necessary. Thomas Edward Mitton House DS0000015072.V359505.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed in the interests of service users. There are good quality assurance systems in place to ensure that the care and service is of a consistently good standard and that the best outcome for service users is achieved. EVIDENCE: The registered manager is a clinical psychologist who has twelve years experience in working with people with an acquired brain injury. She has not yet completed the National Vocational Qualifications in Management at level 4 but has recognised this in the Annual Quality Assurance Assessment (AQAA) statement and included gaining this qualification in the plans for improvement in the next twelve months. She has updated her psychological training regularly. The Disabilities Trust has a good quality assurance programme in place. There was evidence that regular auditing of care outcomes and the service that is
Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 22 offered is undertaken. A service manager visits the home on a monthly basis and reports of these visits are made and kept in the home. There is a clinical incident reporting system in place. Service users have access to local advocacy support if they wish. The home is also accredited by the Commission on Accreditation for Rehabilitation Facilities, (CARF) and Investors in People (IIP). Feedback is sought from service users and an annual report is produced which contains the outcome of the feedback. The manager states that the annual report is available to service users, their families another stakeholders. There are health and safety policies and procedures in place. The training records showed that most staff had had training in safe working practices, including moving and handling, food hygiene and infection control. A fire risk assessment has been undertaken and staff were aware of the evacuation procedures. The maintenance records are updated regularly and safety checks on hot water temperatures are undertaken regularly. Staff health and safety meetings are not held regularly although the service manager said that this was a regular agenda item on the staff meetings. The Annual Quality assurance assessment submitted by the service manager did not contain any information relating to Standard 42 of the national Minimum Standards, apart from stating that there are health and safety policies and procedures in place. It is recommended that she reviews the operation of these procedures in the home in line with guidance published by the Health and Safety Executive entitled ‘Health and Safety in Care Homes’. Further information can be obtained from their website www.hse.gov.uk. Thomas Edward Mitton House DS0000015072.V359505.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 X 2 4 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 4 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 4 X X 2 X Thomas Edward Mitton House DS0000015072.V359505.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. Standard Regulation Requirement Timescale for action 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 Refer to Standard YA32 YA33 Good Practice Recommendations Fifty percent of care staff should hold the National Vocational Qualifications in Care at level 2. The Head of Care or the Rehabilitation Support worker, where they are the key worker, should be invited to service user’s review meetings to ensure that the observations of those who work with service users on a regular daily basis are included in the discussions. The service manager should complete the National Vocational Qualifications in Management at Level 4. The service manager should review the operation of the health and safety policies and procedures in the home in line with guidance published by the Health and Safety Executive entitled ‘Health and Safety in Care Homes’. Further information can be obtained from their website www.hse.gov.uk. 3 4 YA37 YA42 Thomas Edward Mitton House DS0000015072.V359505.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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