Care Home: Mount Carmel Residential Home

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What the care home does well What has improved since the last inspection? The issues raised in the last inspection report have been addressed and the information we asked for provided. This included updating the statement of purpose and service user guide, telling us when building works start on the new extension and to address outstanding issues from previous inspection, arranging moving and handling training, and making sure we get monthly reports about the conduct of the home. The recommendations have also been acted upon and there was a marked improvement in the quality of person centred information held in the care plans this time. Other improvements have been most notably with the building and include the front aspect of the building that has been much improved with the replacement of the bay windows. The lower ground floor bathroom has been totally refurbished and a walk in bath installed. Some bedrooms and communal areashave been redecorated and some furnishings and fittings replaced with further deliveries of lounge chairs imminent. Large screen TV`s have been bought. On completion (planned for before Christmas 2008) the work currently underway with the building will see the drive and car park block paved, a new kitchen and extended dining facilities, a new energy efficient heating system with backup boiler, new fire detector and emergency lighting system, improved laundry facilities and equipment, conservatory that can accommodate all people living at the home (twenty when the extension is completed), additional bedrooms, improved privacy locks to all bedrooms, improved office and staff facilities and improved gardens. This will greatly improve the quality of life and living experience for people. The improvements noted above made over the last year, will not necessarily be seen by people and relatives but do effect and improve the overall quality rating of the service. What the care home could do better: Two requirements are made as a result of the inspection visit. The first in recognition of the difficult living for people situation is in connection with the building works and making sure that the work is scheduled to minimise disruption to people and complete and register as soon as possible. When completed the living situation will be greatly improved. The second is in respect of staffing levels and this inspection found levels were not adequate in the evenings and weekends. The owner gave an undertaking that he would address this. CARE HOMES FOR OLDER PEOPLE Mount Carmel Residential Home 88 Church Lane Leeds West Yorkshire LS15 8JE Lead Inspector Paul Newman Key Unannounced Inspection 21st October 2008 09:30 X10015.doc Version 1.40 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 Mount Carmel Residential Home DS0000070795.V372806.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 Older People. 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. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Carmel Residential Home Address 88 Church Lane Leeds West Yorkshire LS15 8JE 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) 0113 2644441 Mount Carmel Care Ltd Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 13 10th January 2008 2. Date of last inspection Brief Description of the Service: The home is located in the Crossgates area of Leeds. It is a detached house close to local shops, churches, pubs and services. Local bus services are just a few yards from the home. The home can accommodate up to thirteen service users who have no specialist care needs. Nursing care is not provided but the home is supported by local health care services. Bedrooms are on three levels and all can be accessed by a passenger lift that has been fitted in a new extension. Six bedrooms are en-suite one of these being a shared room. Information about the home is provided in the form of a statement of purpose and service user guide. Both these documents are available at the home and should be regularly updated by the home and should outline the terms and conditions for residents. This does not include The homes weekly charges are £410 to £417. hairdressing or private chiropody. The figure was provided at the time of the inspection on 21/10/08 and is subject to annual review. Mount Carmel Residential Home DS0000070795.V372806.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. The accumulated evidence in this report has included: • • • • • • The previous key inspection. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. Relevant information from other organisations. What other people have told us about the service. Information obtained from people living at the home, relatives, staff and other health care professionals. One inspector made an unannounced visit to the home that lasted six hours on 21 October 2008. Before the inspection visit, the manager was sent an Annual Quality Assurance Assessment (AQAA) to complete. This is a self-assessment that if completed properly, should give us a lot of information about how the home is operating, what improvements it has made and what is planned for the future. It tells us where we can find evidence that the home is meeting National Minimum Standards. The AQAA that was returned was clear and gave us information that helped plan the inspection, but could have provided more detail and this was discussed with the manager. During the visit, a number of documents were looked at and all areas of the home used by the people living there were inspected. Apart from spending time with the manager and deputy manager, a good proportion of time was spent speaking to other staff, people who live at the home and visitors. Time was also spent in communal areas and the dining room, watching what was going on and checking whether people appeared comfortable and cared for. Some surveys were sent out before the inspection visit for people living at the home, relatives and friends, healthcare professionals and staff to express their views on how things operate, the services and care provided. Surveys were returned from eight people using the service, three relatives, and two staff and the general feeling showed people being quite satisfied with the care and services provided. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 6 Feedback was provided at the end of the inspection to the manager and one owner. Feedback included an analysis of the results of the surveys and a copy of the analysis was left with the manager so that the home could address any issues raised. What the service does well: What has improved since the last inspection? The issues raised in the last inspection report have been addressed and the information we asked for provided. This included updating the statement of purpose and service user guide, telling us when building works start on the new extension and to address outstanding issues from previous inspection, arranging moving and handling training, and making sure we get monthly reports about the conduct of the home. The recommendations have also been acted upon and there was a marked improvement in the quality of person centred information held in the care plans this time. Other improvements have been most notably with the building and include the front aspect of the building that has been much improved with the replacement of the bay windows. The lower ground floor bathroom has been totally refurbished and a walk in bath installed. Some bedrooms and communal areas Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 7 have been redecorated and some furnishings and fittings replaced with further deliveries of lounge chairs imminent. Large screen TV’s have been bought. On completion (planned for before Christmas 2008) the work currently underway with the building will see the drive and car park block paved, a new kitchen and extended dining facilities, a new energy efficient heating system with backup boiler, new fire detector and emergency lighting system, improved laundry facilities and equipment, conservatory that can accommodate all people living at the home (twenty when the extension is completed), additional bedrooms, improved privacy locks to all bedrooms, improved office and staff facilities and improved gardens. This will greatly improve the quality of life and living experience for people. The improvements noted above made over the last year, will not necessarily be seen by people and relatives but do effect and improve the overall quality rating of the service. 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. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 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 Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. People have written information about the home to help them decide if the home is suitable for them to live in. People are properly assessed before admission so all concerned can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is currently having some extensive alterations to improve and extend the building. When registered this will increase occupancy. The last inspection report noted that the statement of purpose and service user guide Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 10 were out of date and these have been reviewed and will need further review to reflect the changes in facilities. The manager is fully aware of this. Three care plans were checked to establish that pre-admission assessments had been carried out. The recommendations made in the last inspection report have been acted upon and the assessments seen had much more detail about the person’s lifestyle preferences and choices. This makes sure that staff are able to know the person and how they like to lead their life, what they like and dislike, as well as their essential care needs. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. The care plans provide clear instructions for staff to follow making sure that health and personal needs are met. The people at the home are treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three case files that were checked showed that information had been accurately used from the pre-admission assessment to draw up the plan of care. The surveys that were returned confirmed that people and/or their relatives had been involved. The plans addressed individual health and personal care needs. The plans offered sufficient guidance to staff for them to know what each person’s care needs are, and how they should go about addressing these. The home has been trying to develop the care plans to Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 12 make them more ‘person centred’ so that there is more information about peoples’ personal preferences, preferred lifestyle and their life history. There was evidence of this on the files seen. It is this detail that fully evidences that staff are made aware of peoples’ preferences, although in speaking to people at the home, watching what was going on and speaking to staff, it is clear that they know the people they care for very well. On admission, a range of risk assessments are made for moving and handling, nutrition, dependency and pressure sore risk. These are reviewed regularly. People have their weight recorded at least monthly and there was evidence to show that any significant changes are referred to the GP. Other healthcare professionals are consulted when required and these include the dietician, tissue viability nurse, and community psychiatric nurse. Medication procedures and practices were discussed and seen, and the storage and the recording of drugs that are administered were checked for the three people whose care plans were seen. No problems were found and practices that were seen were safe. All personal care and visits from healthcare professionals and Doctors are carried out in the privacy of people’s own bedrooms. During the inspection, staff were seen knocking on bedroom doors and making sure that doors were closed at times when personal care was being delivered. People spoken to said that that staff are attentive to their needs and wishes. Generally the views expressed in the surveys returned were positive any specific comments were made anonymous and fed back to the manager for action. These are some of the views that were representative of how people feel about the home: • • ‘They look after my Aunty expertly. Nothing at all to complain about’. ‘Staff are helpful to my mother and myself. They will take the time to talk with me as they know I sometimes find it difficult to cope with my Mother’s moods’. ‘Empathise well with the residents. Speak to them in a kind and caring manner’. ‘The staff are friendly, caring, helpful, cheerful and patient. Because it is a small home with few residents, it is less confusing for my Mother’. What the home does well: ‘Well everything. Can’t grumble about anything. If I ask they will tell you. I am satisfied with everything’. ‘I want for nothing and get good food’. ‘I like the home very much’. • • • • • • Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. Peoples’ social expectations and personal preferences are met and they are able to exercise choice in their lifestyles so they can be as independent as they can. People living at the home are provided with a varied and nutritious diet so they can eat healthily. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Conversations once again found people to be very happy with the range of activities provided. The comments made during this visit reinforce the good work and successful encouragement in getting residents active and involved. There is a programme of activities that includes both in-house things as well as trips out like pub lunches and shopping trips to the nearby Arndale Centre. One relative commented that ‘the home arranges a lot more activities than Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 14 they used to do, getting the residents to interact with others and be entertained’. The home regularly takes local students for work placements and on the day of the visit one student was spending time chatting with people. This is a useful addition to staff time and people appear to really enjoy the attention of the younger people. A volunteer continues to come in twice weekly to organise activities. The discussions with staff and conversations with people they care for once again showed that individual likes, dislikes and preferences are known. This includes getting up and going to bed when you wish, what you wear each day, the foods you like or don’t like, whether you want to spend time alone in your room and what activities you get involved in. Some people spend time together in bedrooms chatting and watching TV and have built good friendships. People are encouraged to express their views and choices about the food provided on a daily basis. The people spoken with on the inspection visit confirmed that the food was good and they had enjoyed the lunchtime meal. Staff were seen giving good sensitive support and encouragement to those people who needed assistance. The current dining room is somewhat cramped but the improvements that are being made will greatly improve the dining experience. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. The people who live at the home and their relatives know how to complain and feel confident that they will be listened to and that action will be taken when necessary. There are adult protection procedures that staff are aware of through training, so people can be assured that they can feel safe because staff know what to do. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The home aims to deal with situations as they occur, and encourages families to discuss any area of concern with the manager or staff on duty at the outset. In the conversations with people during the day and in the written comments made in surveys that were returned, this was clearly the normal way of doing things. People felt comfortable about raising things and said that they were listened to and actions were taken. One comment made was, ‘if there was something I didn’t like, I would speak out about it’. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 16 Where formal complaints have been made, these have been investigated under the appropriate procedures and properly documented. The complaints procedure is displayed in reception and also in service user guides that are provided. Protection of Vulnerable Adults training is ongoing for staff and is mandatory training. This is also discussed with staff at staff meetings and individual supervision sessions. Other checks made on recruitment, safekeeping all met required standards. medication and money held for Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience adequate quality outcomes in this area. People living at the home live in a clean, comfortable and safe environment that has significant improvements, refurbishment and extentions currently being carried out. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The current living situation is somewhat difficult because of the extensive improvements and extension being built. The people spoken to generally accept that this was for the good and accepted that there would be some upheaval from time to time but the drilling and sawing noises were the biggest Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 18 grumble. It was however also creating interest. The owner and builders are scheduling work so that it the least impact or potential for upset to people living at the home, and it is hoped completion will be by Christmas. Since the last inspection the front aspect of the building has been much improved with the replacement of the bay windows. The lower ground floor bathroom has been totally refurbished and a walk in bath installed. Some bedrooms and communal areas have been redecorated and some furnishings and fittings replaced with further deliveries of lounge chairs imminent. Large screen TV’s have been bought. On completion the work currently underway will see the drive and car park block paved, a new kitchen and extended dining facilities, a new energy efficient heating system with backup boiler, new fire detector and emergency lighting system, improved laundry facilities and equipment, conservatory that can accommodate all people living at the home (twenty when the extension is completed), improved privacy locks to bedrooms, improved office and staff facilities and improved gardens. This will improve the quality of life and living experience for people. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. People living in the home are cared for by committed staff who are properly recruited and trained for the job, but staffing levels must be reviewed to make sure there are enough staff on duty at all times. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and staff spoken with and the dependency levels of people discussed. Surveys returned by relatives had indicated that there might not be enough staff on duty at weekends. From the discussions and rotas seen it was evident that during the evenings and weekends there were not enough staff to offer people the care they needed at all times and if there were an incident or procedure like hoisting that required two staff, other people were left vulnerable. This was raised with the owner who agreed to address this. Nevertheless, during the visit, people were getting good attention from staff and good support at times when they needed personal care. People once Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 20 again made positive comments about the caring qualities of the staff and the relationships were warm, some people describing things as just like living at home with your own family. This has been a familiar and repeated view expressed by relatives and people living at the home. Personnel records were checked for the two most recently appointed staff and it was found that the home makes sure that the appropriate checks are made. All staff had application forms, a contract, job description, training log, two references, one being from the last employer, and checks had been made with the Criminal Records Bureau. This makes sure that people are protected from staff who may not be suitable to work in the care industry. The home continues to exceed targets set for the number of staff who should have a National Vocational Qualification (NVQ). The manager said that she was reviewing the training programme and plans for the next year with the representative of training company that the home uses, and she is hoping to get some client specific training like dementia in the programme. The staff on duty talked about the training that they had done over the last year and this appeared to cover the essential safe working practice updates. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. The opinions and interests of the people are central to the way the home is run and there is a clear approach to resident care that is person centred and is the focus of staff practice. Safety checks and systems of communication make sure that the home is a safe place to live. We have made this judgment using available evidence including a visit to this service. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 22 EVIDENCE: The person appointed as manager last year has worked at the home for a long time and has the Registered Manager’s Award and will now make a formal application the CSCI for registration so that this ties in to the completion of the extension and building works and application for increased occupancy of the home. There is a relaxed and family atmosphere in the home. People and their relatives are surveyed to check that they are satisfied with things and the results of the surveys were made available during the visit. On a daily basis it was also clear that staff regularly check on the wellbeing of people making sure they are comfortable or if they need anything. As was seen on the day of the visit, the owner is almost a daily visitor to the home and is fully involved with things. He was assisting a builder in the new extension. The home is now a member of the Leeds Care Homes Association that gives access to advice, support, training and conferences. The owner is now providing monthly reports to the Commission that help us monitor the developments in the home. The system of keeping money for people for safekeeping remains unchanged, but a further random check was made of one person’s records with the cash kept. This was sound. Staff were seen to be wearing appropriate protective clothing to prevent cross infection and safety checks are made of the facilities and equipment to make sure the home is a safe place to live. The housekeeper and staff team do well to make sure the home is clean and free from unpleasant odours. Staff are trained in safe working practices and are up dated regularly. Some records of safety checks were seen and found to be up to date. Accident records were also checked and were properly recorded and are audited by the manager to check if risks can be reduced. The AQAA confirmed that equipment and facilities are checked regularly to make sure it is in good and safe working order. Mount Carmel Residential Home DS0000070795.V372806.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 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 X X N/A 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 X X X X X X 3 STAFFING Standard No Score 27 1 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 X X 3 Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 16, 23. Timescale for action The building programme 31/01/09 currently underway must be planned to minimise disruption to people and completed and registered as soon as possible. This will improve the living situation for people and minimise any disruption to them. There must be enough trained 31/01/09 staff on duty to fully meet the needs of people at all times. This will make sure peoples’ safety and welfare is uppermost. Requirement 2 OP27 18 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 OP1 Good Practice Recommendations The home should further update the statement of purpose and service user guide when the extension is completed to DS0000070795.V372806.R01.S.doc Version 5.2 Page 25 Mount Carmel Residential Home 2 OP7 accurately reflect the facilities and services provided. The home should continue to develop a more ‘person centred approach in the care planning documentation so that peoples lifestyle preferences are known to all staff. Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Mount Carmel Residential Home DS0000070795.V372806.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!