Care Home: Mont Calm (Sturry)

What the care home does well The home benefits from a stable and committed staff team who have been provided with a good training package covering mandatory and additional topics. All of the staff within the home have completed a relevant National Vocational Qualification (NVQ) at level 2 or above. Key areas of competency are assessed by the manager on a periodic basis. Comments by relatives and professionals gave positive feedback about the quality of care in the home and the courtesy of the staff. There is an activities co-ordinator who develops a programme of events based on the needs of groups and individuals. Work completed is on show and pictures of activities adorn the walls. Service users have an active and interesting lifestyle. The home has detailed pre-admission assessment processes and has developed informative and targeted care plans and risk assessments. Healthcare assessments are completed and relevant professionals involved in addressing identified needs. Nutritional assessments are monitored and a healthy, balanced diet is offered providing for specialist diets where required. Complaints and concerns are taken seriously and investigated where required through formal processes. Staff have received information and training covering the issue of safeguarding vulnerable adults. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.2 What has improved since the last inspection? The registered provider has made significant improvements in relation to the environment. An action plan was submitted following the previous inspection, which has been adhered to. Medication processes have been reviewed and improved providing safe working practices. Quality monitoring systems have been developed and the service receives a monthly monitoring visit and gains feedback from interested parties. Staff have attended training in infection control issues and the home has applied advice received from professionals in this regard. Lockable cabinets have been provided for all service users to keep their valuables in as assessed. What the care home could do better: 1 requirement and 6 recommendations have been made as a result of this inspection process under the Care Standards Act 2000. The home is to required to continue with planned environmental improvements in accordance with the submitted action plan. It has been recommended that daily record keeping systems are reviewed and updated. An evidence-based induction programme for new staff should be developed and proof of identity kept on file for all staff. The organisation should continue to develop accountable and focussed quality monitoring processes. An up to date electrical wiring assessment should be completed by a suitably qualified and approved electrician. The manager is also recommended to develop improved systems for reviewing care planning information. Key inspection report CARE HOMES FOR OLDER PEOPLE Mont Calm (Sturry) Star Lodge Park View Sturry Canterbury Kent CT2 0NW Lead Inspector Joseph Harris Key Unannounced Inspection 14th September 2009 10:00 DS0000035711.V377693.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mont Calm (Sturry) Address Star Lodge Park View Sturry Canterbury Kent CT2 0NW 01227 710897 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) Stephen Anthony Castellani Mrs Susan Teresa Hancox Care Home 16 Category(ies) of Dementia (0) registration, with number of places Mont Calm (Sturry) DS0000035711.V377693.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. Dementia (DE) The maximum number of service users to be accommodated is 16. Date of last inspection 17th September 2008 Brief Description of the Service: Mont Calm (Sturry) is a large modern detached house, which offers one shared bedroom and fourteen single bedrooms for residents. The home provides care and accommodation for up to 16 people who are 65 years of age or older and have dementia. There are local facilities nearby and access to public transport. There are parking places at the front of the building. There is a garden for residents use at the rear. Current fees are available in the service user guide and are based on assessed personal needs. Please contact the manager for further details. Mont Calm (Sturry) DS0000035711.V377693.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 2 star. This means the people who use this service experience good quality outcomes. This key unannounced inspection process culminated in a site visit to the home on 14th September 2009. The site visit commenced at approximately 10am and concluded at 4pm, lasting for around 6 hours. During the course of the visit a tour of the premises was undertaken and discussions were held with the registered manager, staff members and service users. A range of documentation was examined relating to the residents, staff, medication, health and safety and the day-to-day running of the home. The home also returned the Annual Quality Assurance Assessment (AQAA), which provides information to inform the inspection process. Surveys were returned by 3 relatives of people who use the service, 3 staff and 4 social or health care professionals. What the service does well: The home benefits from a stable and committed staff team who have been provided with a good training package covering mandatory and additional topics. All of the staff within the home have completed a relevant National Vocational Qualification (NVQ) at level 2 or above. Key areas of competency are assessed by the manager on a periodic basis. Comments by relatives and professionals gave positive feedback about the quality of care in the home and the courtesy of the staff. There is an activities co-ordinator who develops a programme of events based on the needs of groups and individuals. Work completed is on show and pictures of activities adorn the walls. Service users have an active and interesting lifestyle. The home has detailed pre-admission assessment processes and has developed informative and targeted care plans and risk assessments. Healthcare assessments are completed and relevant professionals involved in addressing identified needs. Nutritional assessments are monitored and a healthy, balanced diet is offered providing for specialist diets where required. Complaints and concerns are taken seriously and investigated where required through formal processes. Staff have received information and training covering the issue of safeguarding vulnerable adults. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.2 Page 7 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 and 6. Service user’s needs are assessed and they and/or their representatives are able to make an informed choice about the home. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a statement of purpose and service user guide in place containing all required information. A copy of the service user guide is provided to all referrers and is available on request. The information contained is up to date and reviewed on a regular basis. A copy of the joint assessment completed by care managers is requested by the service at the point of referral. Prospective service users are then assessed Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 10 in their current accommodation by the service manager using an in-house assessment tool. An example of this was examined and all key areas of need were covered in good detail combining information from care managers, relatives and the service user. A visit to the service is offered and prospective residents can spend time in the home familiarising themselves with the people and environment. Once the placement is agreed the first 4 weeks are considered a trial period. A multidisciplinary team review is held following this to address any issues. Feedback from surveys returned by relatives stated that information about the care service is provided well. The service does offer respite care on an informal basis dependent on the availability of beds. There are no dedicated intermediate care facilities. The manager stated that the standard admission processes apply and service users on respite care are encouraged to socialise with in the home. A programme of activities is adapted by the activities co-ordinator to support individual needs and preferences. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The health and personal care needs of service users are met. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Two individual service user files were examined containing care plans, risk assessments and healthcare information. In both cases the plans of care had been developed to a good standard. The needs are linked to assessment information and provide clear guidance to enable staff to meet them. The plans are clearly aimed at promoting independence focussing on what individuals can do. Activity plans are developed in conjunction with the activities co-ordinator with preferences and wishes identified. Relatives are Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 12 involved in the care planning process where possible and plans show evidence of monthly review. One care plan was not dated or signed, which the manager agreed to amend. It was suggested that the review sheet could be developed further to provide a brief summary of any changes made. Refer to recommendation 1. A range of risk assessments have been developed covering both generic and individually assessed risks. The assessments detail measures to minimise perceived risks and are reviewed every month. They are developed in manner that promotes the independence of the service users. Daily records were examined and discussed with the manager. At present a tick box chart is used covering health and personal care issues, additional information is recorded on the reverse. In one example examined the written information was sporadically completed without any evident structure. Ticks entered in the charts were not signed therefore lacking assumed responsibility. The manager stated that the system is under review. It is recommended that a more informative, organised and accountable system of daily recording is introduced. Refer to recommendation 2. Healthcare records show evidence that the needs of residents are referred to relevant professionals. The home undertakes a number of assessments including manual handling, pressure area care and nutrition. This information is used to inform plans of care and risk assessments. The manager reported that the home and service users receive good support from health and social care agencies including mental health teams, GPs and District Nurses. Complimentary healthcare practitioners such as chiropodists and opticians visit the service regularly. Medication processes were examined and demonstrated that the home manages the medication requirements of service users well. There is evidence that the service liaises well Responsible Medical Officers and pharmacy services. Medication Administration Records (MAR) are managed, all documents seen were complete and up to date. Policies and procedures are in place and all staff administering medication have received appropriate training and undertake regular competency assessments. The storage facilities are adequate, it was reported that once the building extension is completed there will be a dedicated medication storage area. Controlled drug storage facilities are awaiting delivery; there are interim secure storage arrangements. Records of controlled drug administration are maintained as are the returned/destroyed medication records. Information about each medication used is kept on service user’s files and it is recommended that a copy of this information is also retained with the MAR charts. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Service users have a lifestyle that meets their needs. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: It was evident that service users enjoy a stimulating and varied lifestyle in the home. An activity co-ordinator works 3 days per week organising a range of sessions and events. Examples of work done in arts and crafts sessions are on show and they display that a variety of abilities are catered for. A therapist visits weekly for an exercise session and visiting entertainers are booked regularly. The home hires a minibus for outings and a number of trips were organised throughout the summer. Staff stated that they have time to play games and socialise with residents informally. Residents and staff were observed to interact positively. The home displays many photographs of Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 14 parties, outings and events, which not only provides evidence of activities, but also has positive reality orientating therapeutic effects. Visitors are welcomed into the home at all reasonable times and the manager recognises the importance of continuing family involvement. Surveys were returned by relatives prior to the site visit all providing positive feedback about the quality of care in the home. One comment was, ‘We find them very friendly, helpful and trustworthy and would recommend them to anybody. They look after my Dad’s needs.’ Other visitors present during the site visit said, ‘it’s lovely; very nice.’ A discussion was held with the home’s full-time cook who appeared very enthusiastic about his role. He said, ‘the equipment is good and we always have fresh food’. He stated that the home places a high importance on good diet and this is supplemented by nutritional assessments and carefully planned menus. The home has achieved an award for providing specialist diets from the Vegetarian Living Society. The chef said all nutritional requirements are catered for. The kitchen facilities have been recently upgraded and were clean and hygienic. A mealtime service was observed that was a social and relaxed time. Staff appeared unhurried and were available to support residents sensitively. They demonstrated an ability to manage issues calmly as they arose. Many of the plates returned empty and residents are provided with visual choices as much as possible, such as a sweet trolley. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Service users are protected from abuse and complaints managed appropriately. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a clear and accessible complaints procedure that is summarised in the service user guide and displayed in the home. The majority of issues are dealt with on an informal basis, but the formal complaints process is invoked if this proves unsatisfactory. Formal complaints are logged on a recording sheet and the outcome of any enquiries and actions noted. The home has received one complaint in the past 12 months which was managed appropriately. Policies and procedures relating to adult protection and abuse awareness are in place. All staff have received up to date training covering adult protection issues. There is also information available regarding the Mental Capacity Act and Deprivation of Liberty Safeguards. Senior staff have undertaken training on these topics. Staff spoken to demonstrated a good understanding of the issues related to this. The home made one referral to the Safeguarding Vulnerable Adults alert, which was not required to be investigated and closed. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 16 Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. The premises are suitable for the service user’s needs. Further work is required to update the environment. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A tour of the premises was undertaken which demonstrated that improvements have been made to the environment. The service provider submitted an action plan following the last key unannounced inspection and, with the exception of planned major building works, has addressed all of this issues previously raised. The home is planning to build an extension, which will Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 18 provide improved facilities, space and disabled access to the garden. This remains a key part of the necessary improvements and is required to be completed as per the action plan. Refer to requirement 1. A programme of on-going decoration and refurbishment has commenced with new carpets throughout the house, new furniture in communal areas and redecoration. A new stair lift has been fitted. A shift lift is planned as part of the redevelopment plan. The kitchen and some bathrooms have been updated. Access to the rear garden is still via a stepped exit through the kitchen, but a ramp has been fitted for easier egress. The home benefits from a large lounge/dining area and 14 single bedrooms and one double room. The rooms range in size and where possible people who use the service are offered larger rooms. Room sizes are recorded in the service user guide. The bedrooms viewed contained suitable furnishings and fittings and had been personalised according to taste. Lockable cabinets are now available in each individual’s bedroom. Service users have been assessed for their competency to retain keys. There are suitable numbers of bathing and toilet facilities throughout the building that are accessible to service users with and without support. The home was clean and hygienic on inspection and hazardous substances stored securely. Staff have received training in infection control and health and safety issues. Monthly health and safety audits are completed. The laundry is situated on the third floor, which is not ideal, but is due for relocation on completion of the extension. It was reported that the home meets the requirements of the environmental health and fire safety departments. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. There is a competent staff team in sufficient numbers. Recruitment practices are followed. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All of the staff team including cooks and housekeepers have completed at least an NVQ level 2 award, a number of the care staff have now commenced to NVQ level 3. Discussions were held with some of the staff on duty who were knowledgeable about the client group and individual needs. This was supported by feedback from professionals involved with the home who made comments such as, ‘the staff are always professional and helpful’ and ‘they always provide a warm welcome.’ The manager ensures on-going support through formal supervision, team meetings and competency assessments covering key topics. Staff stated that they feel supported and that a good training programme is in place. According to records all staff have completed courses covering mandatory topics and many have had additional training including dementia awareness, diabetes, Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 20 risk assessments and adult protection amongst other things. No new staff have been employed in the home since the last inspection and it was reported that there is a good retention rate and low sickness levels. An induction programme is in place for all new staff to work through; this is in the process of being updated to become more evidence based in line with the common induction standards. Refer to recommendation 3. There are suitable numbers of staff on duty at all times to meet the needs of the service users. In discussion, staff confirmed that they are able to fulfil their roles and they were observed to be unhurried and relaxed in the course of their duties, having time to stop and talk with residents and visitors. This was supported by feedback through surveys from relatives and staff. Two staff personnel files were examined that contained all required recruitment information including two written references, CRB checks and completed application forms. No proof of identification had been retained on file, which the manager agreed to address. Refer to recommendation 4. Staff confirmed that appropriate checks had been carried out before they commenced work and that they had completed an induction programme. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The home is run in the best interests of the service users. Health and safety issues are maintained. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The registered manager has been in her post for a number of years and she has attained all the required qualifications for the purpose of her role. Staff commented that she has an open approach and manages the home in a Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 22 positive manner. In discussion she demonstrated strong values promoting a proactive approach to care. The area manager has developed improved quality monitoring processes that include monthly monitoring visits and annual surveys. Relatives stated that they are asked for their opinions and are involved appropriately in care and planning. The quality assurance systems are still being developed and aspects such as clear action plans and collating survey feedback would benefit from being introduced. Refer to recommendation 5. The home does not act as a financial appointee for service users; this responsibility is taken on by people independent of the home. A safekeeping service is provided and records and receipts kept of all incoming and outgoing transactions. Records relating to health and safety were examined. The home carries out monthly health and safety audits and reports any issues arising for attention to the service provider. Fire safety logs are well maintained and a comprehensive fire risk assessment is in place. Service safety certificates are up to date including gas safety, hoists and other appliances. It was noted that the electrical wiring certificate is recently out of date and an updated test needs to be arranged with an approved NICIEC electrician. Refer to recommendation 6. Accident records are maintained and the home reports any incidents of note to appropriately. Policies and procedures are in place covering safe working practices and mandatory training has been provided. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 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 OP19 Regulation 13(4) Requirement The Registered Provider is to continue to develop the environment in accordance with the action plan submitted to the Commission. Timescale for action 01/01/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP7 OP10 OP30 OP29 OP33 OP38 Good Practice Recommendations To further develop care planning review processes. To review and develop more detailed, accountable and structured daily recording systems. To develop an evidence-based induction programme for new staff. To ensure that evidence of proof of identity is retained on staff files. To continue to develop quality assurance processes providing a clear audit trail from assessment to action. To ensure an up to date electrical wiring certificate completed by an approved electrician is completed and retained on file. DS0000035711.V377693.R01.S.doc Version 5.3 Page 25 Mont Calm (Sturry) Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southeast@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Mont Calm (Sturry) DS0000035711.V377693.R01.S.doc Version 5.3 Page 26 - 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!