Inspection on 08/12/06 for Thomas Edward Mitton House

This inspection was carried out on 8th December 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thomas Edward Mitton House 28/02/08

Thomas Edward Mitton House 08/02/06

Thomas Edward Mitton House 04/10/05

Thomas Edward Mitton House 02/02/05

Thomas Edward Mitton House 05/08/04

Thomas Edward Mitton House 15/01/04

Similar services:

Flint House

The Cotswold Home

Fairways

Treloar College

Rush Court

The Maypole Nursing Centre

Fir Tree Lodge

Chilmington House

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

CARE HOME ADULTS 18-65 Thomas Edward Mitton House Belvoir Avenue Emerson Valley Milton Keynes Bucks MK4 2JA Lead Inspector Joan Browne Unannounced Inspection 8th December 2006 09:30 Thomas Edward Mitton House DS0000015072.V316842.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.V316842.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.V316842.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 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 Care Home 16 Category(ies) of Physical disability (16) registration, with number of places Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 16 people with a physical disability. Date of last inspection 8th February 2006 Brief Description of the Service: Thomas Edward Mitton House is a 16-bedded residential home for people with a physical disability. The aim of the unit is to provide rehabilitation for people with brain injury back into more independent living or to move onto specific units more able to meet their needs. The accommodation consists of 16 single rooms all en-suite. The house has a library and a large dining area, as well as therapy rooms and lounges. 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. Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that took place on 8 December 2006. Prior to the fieldwork visit previous information about the home was reviewed. Comment cards were received from seven service users, three relatives and two health and personal care professionals. Overall they were happy with the care provision. Service users and staff were interviewed. A tour of the premises was undertaken and care records and documentations were examined. The care of two service users was ‘case tracked’ from their original contact with the home to the care that they are now receiving. Care practices and home’s approach to quality and diversity issues were observed. It is considered that this service meets the diverse needs of service users. What the service does well: What has improved since the last inspection? Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 6 Some beds and furniture in service users’ bedrooms have been replaced. Flooring in shower rooms have been replaced. 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.V316842.R01.S.doc Version 5.2 Page 7 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.V316842.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home ensures that prospective service users are provided with the appropriate information they need to make an informed choice about where to live. They are assured that the home will be able to meet their assessed needs and aspirations and are fully involved in the assessment process. EVIDENCE: The home has a Statement of Purpose and Service User’s Guide. The documents are reviewed annually or as and when required. Service users are issued with copies of the documents. Keyworkers are expected to discuss the documents with them as part of their key working time on a regular basis. It was noted that the documents needed to reflect the Commission’s new address and the acting manager’s name and qualifications and the current weekly charges. It is recommended that the documents be updated to reflect the current changes. The home ensures that prospective service users are assessed prior to admission. The home’s clinical psychologist and staff who are competent and experienced undertake all assessments, which are carried out in a sensitive manner. The home would obtain a summary of any assessment undertaken through care management or any information that may be relevant from family members. The prospective service user is initially visited by the home’s Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 9 staff in their home or in hospital. Arrangements are then made for the prospective service user to be invited to the home and undertake an assessment. A detailed report is prepared following the assessment. And a clear detailed action plan is developed outlining how the assessed needs would be met. Copies of reports were seen in those service users’ files whose care was case tracked. The home has a reputation of being able to work with service users whose needs are very complex and challenging. Any potential restrictions on individual’s choice, freedom, services or facilities are discussed with the service user and his/her representative and recorded on the pre-admission risk evaluation checklist sheet. Service users are fully involved in all stages of the assessment process and staff work closely with them to achieve their goals and aspirations. Thomas Edward Mitton House DS0000015072.V316842.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans seen reflected the changing needs and personal goals of service users. Risk assessments are in place and form a very important part of the home’s programme in supporting service users to make decisions about their lives and promoting independence. EVIDENCE: Care plans seen contained the following: functional goals, component subgoals and planned actions and interventions. These were clear and comprehensive and set out how current needs were being met including rehabilitation goals. Guidelines on how staff should be providing positive reenforcement were detailed in care plans seen. Plans contained pictures of service users and evidence was seen to indicate that they were being reviewed regularly to reflect any changing needs with the involvement of the service user, family members and other professionals. Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 11 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 care plans were working documents and staff spoken to were familiar with the contents and were using them to ensure that service users’ diverse needs were being met. Evidence was seen, which indicated that staff were respecting service users’ rights. Wherever possible they were empowered to take control of their lives and to make informed decisions. There was a range of options provided relating to rehabilitation, social and leisure activities for service users to choose and participate in. These consisted of cookery groups, social outings, shopping trips, leisure trips and pub lunches. Service users’ goals and aspirations were recorded in care plans seen and focussed on re-establishing independent living skills or for individuals to be able to mobilise with the use of a Zimmer frame. Wherever possible service users were supported and encouraged to manage their own finances for as long as they are able to. The home was looking after small amounts of money for some service users. The money was not pooled and the appropriate records and receipts were in place. Two transaction sheets checked were satisfactory. Risk taking is identified during the assessment process for individuals. There were assessments with developed strategies in care plans seen. Staff are expected to work with service users within their risk assessment framework to ensure that independence is promoted. Risk assessments seen related to service users being supported by staff to prepare cooked meals several times a week, making hot drinks, tidying their bedrooms and maintaining personal appearance. 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.V316842.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for service users to participate in leisure and social activities in the local community thus ensuring that their cultural and diverse needs were being met. Service users’ rights are respected and independence is strongly promoted within the appropriate risk assessment framework. Meals provided are of a high standard, nutritionally balanced and are served in pleasing surroundings to ensure that individuals’ dietary and cultural needs were being met. EVIDENCE: The home has a vocational trainer who supports service users to enjoy a full and stimulating lifestyle within their capabilities. 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 a daily living programme, which was established during their initial assessment and is focussed on their needs and aspirations, which is regularly reviewed. Thomas Edward Mitton House DS0000015072.V316842.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 interacting with service users sensitively and addressing them by their preferred choice of name. All service users have a key to their bedroom doors. Staff support individuals as part of their rehabilitation programme to prepare meals, look after their personal laundry or to use the social facilities in the local community. On the day of the inspection some service users participated in a cookery class and made chocolate cakes. A further two service users went out for lunch with their keyworker There was evidence in care plans seen that service users were encouraged by staff to maintain family links and personal relationships. Some service users as part of their rehabilitation programme return home at weekends to spend time with family members. The lunchtime meal was observed, which consisted of fried or boiled fish, chips, mashed potatoes, peas and baked beans. A choice of fresh fruit and yoghurt was on offer for dessert. Lunch appeared to be 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. Thomas Edward Mitton House DS0000015072.V316842.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 & 20 Quality in this outcome area is Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users’ personal and health care needs were being. Medication procedures are in place however, they are not always followed, which may put service users at risk. EVIDENCE: Care plans seen indicated the level of assistance that staff needed to provide to service users when assisting with personal care. They confirmed that personal care was always provided in private and with dignity. Individuals’ preferences on how they wished to be supported with moving and handling were recorded in care plans seen. They were able to choose what clothes they wished to wear, hairstyle and makeup to ensure that their appearances reflected their personalities. It was noted that some service users were receiving one to one care daily by staff who were familiar with their care needs. The home ensures that service users have access to technical aids and equipment to maximise their independence. Specialist support and advice from the home’s physiotherapist, occupational therapist and speech therapist is available when needed. Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 15 All service users were registered with a general practitioner and get support from the consultant neurology-psychologist and neurology-psychiatrist. The home’s staff work closely with the continence adviser and other health care professionals. Arrangements were in place to ensure that regular health care checks such as dental, optical and chiropody are carried out. Service users are also able to access national health service treatment via the general practitioner. The home uses the Manrex monitored dose medication system. The medication administration record (MAR) sheets were checked and some unexplained gaps were noted. The receipt of medication received was not recorded on the MAR sheets. However, a record of drugs returned to the pharmacist was being maintained. It was noted that two staff members did not always check handwritten entries recorded on MAR sheets. It is strongly recommended that two staff members to reduce the risk of errors being made should check all handwritten entries recorded on MAR sheets. The medication trolley and storage cupboard were checked and were clean and tidy. The controlled medication storage cupboard complied with current regulations. The controlled drug register and medication were checked and were satisfactory. Two signatures were evident for the administration of controlled medication. The home encourages independence and wherever possible service users who have the capacity to self-medicate are encouraged to do so with the appropriate risk assessment in place. However, there were no service users self-medicating at the time of the inspection. There was evidence that those staff who administer medication had undertaken the appropriate accredited training. It is further recommended that the practice of administering medication at the same time service users are eating their lunch should be reviewed. Thomas Edward Mitton House DS0000015072.V316842.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place that service users are aware of and have confidence in. There are also policies and procedures in place to protect service users from abuse and staff undertake regular training. EVIDENCE: Information recorded on the pre-inspection questionnaire indicated that since the last inspection the home had received two complaints. They were investigated by the home and it is considered that the regulations in relations to complaints have been met. No complainant has contacted the Commission with information concerning a complaint. Service users spoken to said that they were aware who to speak to if they had a concern. They felt that there was an open culture in the home and they were able to share their concerns with staff. The home conforms to its organisation’s protection of vulnerable adult (PoVA) and whistle blowing policies and liaises appropriately with other agencies. Information submitted on the pre-inspection questionnaire under section D6 indicated that staff had undertaken training in the protection of vulnerable adult. Staff spoken to demonstrated a clear understanding of what action they would need to take if they suspected or witnessed a service user was being abused. Thomas Edward Mitton House DS0000015072.V316842.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home, which is safe, clean and hygienic. There are appropriate aids and equipment provided in bedrooms and communal areas to promote independence. EVIDENCE: Thomas Edward Mitton House has been purpose built and is situated on one level. It has wide spacious corridors. Bedrooms have en suite facilities with built in wardrobes, chest of drawers, a bed and a chair. Rooms were personalised, with personal belongings such as stereos, family pictures and mementoes that reflected the characters of individuals. The house offers a homely environment, and furnishings were of a good quality. The home has a library room, which is also used as a meeting room, a dining room, activity room, and sitting room. There is a physiotherapy room equipped with the appropriate equipment and two small kitchens, which service users have access to and which are used by the occupational therapy staff for individual cooking sessions. The conservatory area is used as a smoking area. Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 18 The home has adequate laundry facilities. The laundry room appeared clean and tidy and is situated away from where food is stored and prepared. Communal areas within the home were found to be clean, tidy and free from odours. Thomas Edward Mitton House DS0000015072.V316842.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, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedure complies with current legislations to ensure that staff who are appropriately vetted care for service users. Training records indicated that there is an ongoing training programme to ensure that staff who are appropriately trained meets the diverse needs of service users. EVIDENCE: Staff undertake regular training to ensure that they acquire the appropriate skills to care for service users. Seven staff have acquire NVQ (national vocational qualification) in direct care at level 2 and 3 and two were working towards achieving it. All staff providing personal care were over eighteen years of age. The file for the most recently appointed member of staff was examined. It contained two references from previous employers, a completed application form, a declaration of health statement and terms and conditions of employment. A PoVA first check and a criminal record bureau (CRIB) clearance had been obtained. There was evidence to indicate that the employee had undertaken appropriate induction training. Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 20 The home has an ongoing training programme, which is comprehensive. There is also a dedicated training budget and a senior member of the staff team designated to facilitate inhouse training. All staff are expected to undertake a structured induction training that meets the ‘sector for care skills’ criteria. Staff spoken to confirmed that the home ensures that mandatory training is ongoing and regularly updated. The training programme for 2006 included the following: Non- violent crisis physical intervention Manual handling Epilepsy Health and safety Fire Awareness COSHH Adult abuse The home has a structured supervision frame work in place. Staff spoken to confirmed that they receive regular supervision and an annual appraisal. Thomas Edward Mitton House DS0000015072.V316842.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are listened to and consulted with all aspects of their care thus ensuring that they are fully involved in their care and how the home is run. Weaknesses in some health and safety practice in the home have the potential to put service users at risk. EVIDENCE: The home’s registered manager had recently resigned. However, an experienced registered manager from one of the organisation’s homes was currently managing the home until the manager’s position was filled, which was anticipated to be shortly. The acting manager is a registered nurse and has a degree in management. The home’s deputy manager who has been working at the home for approximately thirteen years and is very experienced with working with the client group was supporting her. The home has an open and transparent ethos, which staff and service users can relate to. Staff Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 22 confirmed that the management team was approachable and supportive and regular staff meetings were held. Weekly meetings are held with service users specifically to do with the running of the home. There are also weekly rehabilitation meetings relating to service users’ care needs and their goals and aspirations are reviewed and any changes made are reflected in individuals’ care plans. The home is accredited with investors in people and is working towards achieving a further accreditation known as Commission on Accreditation of Rehabilitation Facilities (CARF) A senior member of staff in the organisation carries out monthly regulation 26 visits and a written report is written. Feedback is actively sought from service users. Satisfaction surveys are sent to service users, their relatives and referrers. These are analysed and any areas highlighted for improvement the appropriate action is taken. The home has a business plan in place, which is based on a systematic cycle of planning and reviewing to reflect the outcomes for service users. Quarterly health and safety meetings take place and copies of minutes of meetings were seen. Twelve comment cards were received in connection with this inspection. Seven from service users, three from relatives and two from health and social care professionals including the general practitioner. All service users respondents said that they liked living in the home, felt well cared for, felt well treated by staff, and knew who to complain to if they were unhappy. All liked the food as well. These views were confirmed in conversations with some service users during the course of the inspection. Relatives were equally positive in their views: all said that they were welcome at any time, could visit the service user in private, were kept informed of important matter, were aware of the home’s complaints procedure and were satisfied with the overall care provided. Additional comments included the following: ‘our family feel that staff are helpful and accommodating. Very pleased with the standard of care provided.’ The home ensures that staff’s moving and handling training is regularly updated. The fire panel and fire drills are normally carried out weekly with staff and service users. It was noted that a full evacuation of the building was recently carried out and staff achieved this task in four minutes and thirty seconds. However, it was noted that the maintenance person had been away for two weeks and there was no written evidence that the fire panel was checked during this period. A requirement is made to ensure that a member of staff must be nominated to check the fire panel in the absence of the maintenance person. An up to date fire risk assessment for the building was in place. It was noted that the door in the lounge was wedged open with an armchair. It is acknowledged that when this was pointed out to staff action was taken immediately and the chair was removed. Staff explained that the chair was used to keep the door open to support a particular service user to maintain Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 23 their independence. However, this practice is not acceptable. Advice must be sought from the fire officer on the most appropriate door holding device or dor-gard that should be fitted to the door to comply with the health and safety regulations 1999. In the interim a risk assessment must be put in place. It was noted that opened packets of food and sauces in the main kitchen was not labelled and dated. It is required that opened packets of food and sauces must be dated to comply with the food hygiene regulations 1995. The home’s cleaner helps out in the main kitchen at lunchtime. It is recommended that the individual’s protective clothing and personal clothing should be completely changed before commencing work in the kitchen to prevent the risk of food contamination. Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 24 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 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 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13(2) Requirement Timescale for action 31/01/07 2 YA42 3 YA42 The manager must ensure that staff administer and record medication in accordance with the Royal Pharmaceutical Society guidelines 13(4)(a)(c) The manager must ensure that doors are not wedged open. r Advice on the most appropriate door holding device that should be fitted to the lounge door should be sought from the fire officer to comply with the health and safety regulations 1999. 13(4)(c) The manager must ensure that opened packets of food and sauces are dated and labelled to comply with the food handling regulations 1995 31/01/07 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that the manager should ensure that DS0000015072.V316842.R01.S.doc Version 5.2 Page 26 Thomas Edward Mitton House 2 3 YA20 YA42 two staff members check handwritten entries recorded on the medication administration record sheets to minimise the risks of errors being made. It is recommended that the manager should review the practice of administering medication at the same time service users are eating their lunch. It is recommended that the manager should review the current practice in place relating to protective clothing worn by the cleaner when working in the kitchen. Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thomas Edward Mitton House DS0000015072.V316842.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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