Care Home: Mountfield House

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What the care home does well The home has a committed team of staff who work hard to meet the needs of the people they support and function well as a team. The manager appears committed to providing a qualified workforce. All but one of the care staff has obtained a care award known as NVQ at levels 2 and above, exceeding the National Minimum Standards. Staff receive training in safe working practices in addition to Dementia Care.People are provided with a homely place to live. Bedrooms are personalised and the home is domestic in appearance. Individual`s health needs are well-monitored and appropriate referrals to healthcare professionals made where necessary. We received a number of surveys from staff and people who use the service who considered the home does the following well: `Cares for residents well` `I think the personal care is of excellent standard. Staff are very well trained, meal choice is excellent and residents outings and holidays are great` `The home is always clean and fresh` `The food is nice` What has improved since the last inspection? A number of improvements have been made to the environment to provide people with a more comfortable home to live to include redecoration of a number of bedrooms and communal areas, a new central heating system, new beds, new floor coverings and the rear garden has recently been landscaped. Meetings with people who use the service and their relatives meetings have been introduced. Minutes of meetings held clearly evidence that the manager seeks the views of people in order to improve service delivery. CARE HOMES FOR OLDER PEOPLE Mountfield House 286 Penn Road Penn Wolverhampton West Midlands WV4 4AD Lead Inspector Rebecca Harrison Key Unannounced Inspection 28th April 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 Mountfield House DS0000066683.V362966.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. Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountfield House Address 286 Penn Road Penn Wolverhampton West Midlands WV4 4AD 01902 330017 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) Mrs Sandra Middleton Mr Gary Middleton Mrs Sandra Middleton Care Home 14 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (14) of places Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of Older People is 14 of which 3 Older People can have mild dementia. 12th February 2007 Date of last inspection Brief Description of the Service: Mountfield House is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of 14 Older People to include 3 people with dementia. The home is located in Wolverhampton, close to local amenities and is on a direct bus route into Wolverhampton City Centre. Accommodation is provided over two floors providing 14 single bedrooms and communal areas to include a lounge, dining room and a conservatory. A passenger lift is provided for people with mobility difficulties. Mr & Mrs Middleton are the registered providers and Mrs Middleton is responsible for managing the service. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk The fees charged range from £357.00 - £408.00 per person per week depending on individual needs. This information applied at the time of the inspection and the reader may wish to obtain more up to date information direct from the care service. Mountfield House DS0000066683.V362966.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 stars. This means that people who use this service experience good quality outcomes. The inspection was unannounced and took place on 28th April 2008 by one inspector over 4.5 hours. A range of evidence was used to make judgements about this service to include discussions with service users, staff and the manager/provider, surveys completed by staff and service users, a tour of the premises, quality assurance processes and observation of care experienced by people using the service. We also looked at a number of records to include care records for two people receiving a service, complaints and protection, staff training, recruitment and health and safety records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to Mountfield House for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The manager completed this and some comments have been included within this inspection report. The purpose of the inspection was to assess ‘Key’ National Minimum Standards for Older People. No requirements or recommendations were made as a result of the previous inspection undertaken on 12th February 2007; therefore we focused on how the home had improved outcomes for people using this service. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The home has a committed team of staff who work hard to meet the needs of the people they support and function well as a team. The manager appears committed to providing a qualified workforce. All but one of the care staff has obtained a care award known as NVQ at levels 2 and above, exceeding the National Minimum Standards. Staff receive training in safe working practices in addition to Dementia Care. Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 6 People are provided with a homely place to live. Bedrooms are personalised and the home is domestic in appearance. Individual’s health needs are well-monitored and appropriate referrals to healthcare professionals made where necessary. We received a number of surveys from staff and people who use the service who considered the home does the following well: ‘Cares for residents well’ ‘I think the personal care is of excellent standard. Staff are very well trained, meal choice is excellent and residents outings and holidays are great’ ‘The home is always clean and fresh’ ‘The food is nice’ What has improved since the last inspection? What they could do better: This inspection evidenced that the service has more strengths than areas for improvement. The manager appeared committed to improving shortfalls identified at the time of the inspection to include recruitment practices, record keeping and the refurbishment of bathrooms. Comments from surveys received include: ‘As a whole I believe things are done to the best of everyone’s ability but there could be more information added to key worker records and an improvement in report writing’ ‘Report writing’ ‘Everything is very good, nothing could be done better’ Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mountfield House DS0000066683.V362966.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 Mountfield House DS0000066683.V362966.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, 3 and 5 (standard 6 does not apply to this service) Quality in this outcome area is good People requiring a residential service are provided with the information needed to decide whether this service will meet their needs. They have their needs assessed prior to admission and are given the opportunity to visit to ensure the home is able to meet their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place, which have recently been updated. The philosophy of the home is ‘To provide home from home for all residents’. Discussions with the manager demonstrated that she had a clear understanding of the criteria for admission. Records held on behalf of two people admitted since the last inspection was examined. These evidenced that Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 10 the home obtains detailed Overview assessments completed by the placing authority in addition to carrying out pre-admission assessments prior to offering a service. People are also encouraged to visit the home to meet others using the service and the staff as evidenced in discussions held with a relative during the inspection. Intermediate care is not provided therefore it was not possible to assess Key Standard 6. Mountfield House DS0000066683.V362966.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 Quality in this outcome area is good The health and personal care, which people receive, is based on their individual needs and regularly reviewed. People who use the service are safeguarded by the home’s system for handling, storing and administering medication. The principles of respect, dignity and privacy are put into practice ensuring people are treated as individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People receiving a service are allocated a designated key worker on admission to the home for continuity of care. Care records held on behalf of two people receiving a service were examined. These contained information for the delivery of care however the manager was advised to ensure care plans are more specific in relation to how people prefer their care to be delivered. For example the exact level of ‘assistance’ a person requires with personal care Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 12 tasks. Both care plans had been reviewed at the required frequency and signed by the service user and their representative, which clearly demonstrates that people are involved in planning and reviewing their care. Care plans include aims and evidence consideration has been given in relation to the Mental Capacity Act. Records seen evidence that daily routines are flexible in accordance with individual’s preferences such as rising and retiring to bed and detail all contact with significant others and outcomes recorded. Assessments of risk to service users were available on the care files examined however one did not include a falls risk assessment despite the initial needs assessment identifying that the person was at high risk. This was fully acknowledged by the manager at the time of the inspection and she committed to reviewing this at the earliest opportunity. Records examined evidence that individual health needs are regularly monitored and kept under review and that the home arranges for health professionals to visit as required and appointments and outcomes are recorded. During the inspection a General Practitioner visited the home to undertake a medication review as staff were concerned about the decline in an individuals health. Medication procedures appeared satisfactory at the time of the inspection. The manager reported that all staff have either received training in the safe handling of medicines or currently undertaking the award. The supplying pharmacist has recently completed an audit of the homes medication systems and the report indicates that systems were satisfactory. A new fridge has also been purchased as advised. Records evidence that the manager also undertakes regular audits on medication and committed to undertake assessments on staff to measure their ongoing competence in relation to handling and administering medication. Respecting people privacy, dignity and rights is clearly documented in the homes Statement of Purpose. Observations made and discussions held with people using the service and a visiting relative indicated that this is upheld. During a tour of the home the manager was seen to knock on peoples bedrooms prior to entry and a service user stated ‘Staff here always knock on my door and are very nice to me’. Mountfield House DS0000066683.V362966.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 Quality in this outcome area is good People staying at Mountfield House are provided with varied opportunities to develop and maintain their social and recreational interests and enabled to keep in contact with family and friends. People receive a healthy, varied diet according to their dietary requirements and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The self-assessment completed by the manager states ‘Mountfield has pride in our choice of activities and the staffs dedication to participate in residents holidays’. The range of activities provided is included in the Service User Guide and seen displayed on the notice board in the home. A log of activities undertaken by individuals was seen on the files examined. Activities are discussed during residents and relatives meetings where people are encouraged to make suggestions. Activities are arranged by the home to include a range of inMountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 14 house and day trips in the community. A holiday has also been arranged for a number of individuals to take place in May. During the inspection a number of individuals were engaged in playing a range of board games. People spoken with reported that they enjoy the activities available to include those provided by external entertainers to include arts and crafts, movement to music and sing-a-longs. Comments received by the home from people using the service as part of their quality assurance processes include: ‘I love the trips out’ ‘The holidays and trips are wonderful, staff do a great job’ The visitor’s book evidenced that the home receives many visitors and during the inspection a relative visited the home. Discussions with the relative indicated that she was happy with the care provided, is always made welcome and has attended a Relatives Meeting to discuss the service provided. The manager provided examples of how choice is promoted and daily records examined evidenced that routines are flexible for example rising and retiring. It was reported that people are provided with lockable storage facilities and can retain responsibility for the safekeeping of their money or the home can assist with this. The Menu seen reflected the choice of food offered on the day of inspection and appeared balanced and nutritional. People are offered a choice of two main meals and people spoken with said they enjoy the food offered. It was reported that that four-week menu is due to change shortly and that people are involved in menu planning. It was stated that none of the current people using the service have special dietary requirements although the home is able to cater for this if required. One person stated ‘I always eat the food here. If I don’t like something the staff put me up something else’ Comments received by the home from people using the service as part of their quality assurance processes include: ‘Excellent choice of meals’ ‘Food is very nice’ Mountfield House DS0000066683.V362966.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 Quality in this outcome area is good People who use the service and their representatives are able to express their concerns and have access to a complaints procedure. Procedures are in place to safeguard people using the service from potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure in place and this is available in the homes statement of Purpose, Service User Guide and displayed in the reception. The manager committed to update the procedure in relation to our change of address and role in dealing with complaints. The self-assessment completed by the manager states ‘We listen to service users views and family issues and deal with them appropriately and quickly’. Discussions held with a service user and visiting relative indicated that they had an understanding of what to do if they were unhappy with the service provided. Since the last inspection the home has received one complaint in relation to mislaid laundry, which has since been resolved. We have not received any concerns or complaints concerning this service since the last inspection. A number of compliments were seen recorded in the homes complaint/compliment book and include: ‘I am delighted with the standard of care given at Mountfield House…’ Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 16 ‘It was a very pleasant visit as normal and all the staff are polite and friendly and the home has a lovely atmosphere…It is obvious how much the carers and management do care about the residents’ The manager confirmed that no referrals under safeguarding adult procedures have been triggered since the last key inspection. All staff have attended training in adult protection and the home has a copy of the local multi-agency safeguarding adult policy and procedure. The manager committed to ensuring the homes policy on abuse referred to the local policy as required. Staff also have access to a Whistle Blowing policy and the manager confirmed that no service user has been subject to restraint. The manager committed to reviewing recruitment procedures to ensure people are not placed at risk of harm. Mountfield House DS0000066683.V362966.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 Quality in this outcome area is good The environment has been improved to provide people living at Mountfield House with a clean and comfortable home to live with good infection control procedures in place to protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is situated on the outskirts of the City Centre and provides good access to community facilities and services. The accommodation is provided over two floors. Bedrooms were personalised and the home provides a relaxed and homely atmosphere. Since the last inspection many environmental improvements have been made to provide people with a more comfortable home to live. Improvements include redecoration of a number of bedrooms and communal areas in consultation with individuals, a new central heating system, new beds, new Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 18 floor coverings and furniture in some rooms and rear garden landscaped. Discussions with the manager evidenced her commitment to continue to improve the environment for the people accommodated and assured the inspector that the bathrooms on both floors would be refurbished this year. The home was found clean at the time of this unannounced inspection and no unpleasant odours were detected. The home employs a domestic member of staff who was seen on duty during the inspection. The manager stated that all staff have either completed or are working towards completing a distancelearning course in the management of infection control. Products hazardous to health are appropriately stored and the necessary assessments readily available. Mountfield House DS0000066683.V362966.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 Quality in this outcome area is adequate People using the service are supported by a well-trained, committed staff team, however the homes recruitment procedures must be improved to ensure people are not placed at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Throughout the inspection staff were accessible, good listeners and communicated well with the people using the service. They appeared motivated and committed to their work. Service users and a visiting relative spoken with provided positive comments about the staff team. People considered there are enough staff on to meet the needs of the people using the service. We received a number three surveys from staff who considered the home does the following well: ‘We care for our residents very well’ ‘I think that personal care is of an excellent standard. Staff are very well trained, meal choice is excellent and residents outings and holidays are great’ Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 20 ‘…staff are well trained and have a good understanding of each residents needs’ The manager stated all but one of thirteen care staff employed hold a nationally recognised care qualification known as NVQ at 2 or above, exceeding National minimum Standards. Discussions with the deputy manager indicate that she is due to commence NVQ level 4 shortly. Staffing levels and the deployment of staff was discussed with the manager who considered staffing levels are sufficient in meeting the individual needs of the current people accommodated. The staff rota was an accurate reflection of staff on duty. In addition to care staff the home employs a cook and a domestic member of staff who were on duty at the time of the inspection. One carer and one cook have been recruited since the last inspection. Staff files for both people were examined and failed to contain all of the documentation required by Regulation. Neither file contained a staff photograph although it was reported these are in hand. Start dates were not readily available and neither of the application forms detailed a full employment history. There was no evidence that this had been examined as part of interview process. One person had been employed on a POVAFirst whist waiting for a full CRB disclosure however had not been fully supervised. The manager acknowledged such shortfalls at the time of the inspection that committed to review the homes recruitment practices immediately to ensure people are not placed at risk in the future. Training records, surveys completed by staff and a discussion with a member of staff indicated that staff are provided with good training opportunities. All staff have received training in safe working practices to include service specific training such as dementia. All members of staff are provided with an individual training plan, which details all training undertaken. Since the last inspection the manager has developed a training matrix and examination of this indicates that staff receive training in safe working practices in addition to training in dementia care, medication and infection control. It was reported that new staff undertake induction training to the required specification. Mountfield House DS0000066683.V362966.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, 32, 33, 35 and 38 Quality in this outcome area is good The ethos of the home is based on openness and respect with aspects of performance regularly reviewed to ensure positive outcomes for the people who use the service. Overall the premises are managed and maintained in a manner, which ensures the safety of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mountfield House is owned and managed by Mrs Sandra Middleton who took over the business in March 2006. Discussions held with the manager evidenced that the she has attended a number of training courses relevant to Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 22 her role since the last inspection and has obtained the necessary qualifications required to effectively manage a care service. Discussions held with a relative and people who use the service indicate that they find the manager approachable and open. It is evident that the manager has made a number of positive changes since the last inspection to include improvements to the environment, introduction of relatives and residents Committee meetings and enhanced staff training. The manager has quality assurance and monitoring processes in place. Audits are regularly undertaken to include care plans, medication, the environment, staff training, medication and complaints. Sixteen completed relative and service user satisfaction surveys were available on file and comments include: ‘Couldn’t wish for better’ ‘Sandra is a good leader’ ‘My mom is very happy and well looked after, thank you’ ‘Bedrooms could do with a nice makeover’ The Annual Quality Assurance Assessment (AQAA) forwarded to CSCI was detailed and reflects both the strengths and areas of improvement for the service. It is evident that suggestions to improve the quality of the service are welcomed and the manager has worked towards implementing suggestions made. The management of people’s finances was discussed with the manager who considered procedures to be robust. Records of monies held on behalf of people were available and appeared satisfactory however the manager was advised to ensure that an agreement for money held on behalf of individuals be obtained and how finances are managed be clearly documented in care records. Secure facilities are provided for the safekeeping of money and valuables in people’s own rooms and inventories of all property held. Health and safety procedures appeared satisfactory at the time of this inspection. Certificates for the servicing of equipment are maintained and safety checks are undertaken at the required frequency. Staff receive training in safe working practices and risk assessments have been reviewed since the last inspection. It was reported that both the Environmental Health Officer and Fire Officer have visited the home since the last inspection and that there are no outstanding requirements. Mountfield House DS0000066683.V362966.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 3 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x x 3 Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP29 Regulation 19 Requirement Staff files must contain all the documentation required by Regulation so we can assess the robustness of the provider’s practice in the recruitment, selection and retention of staff to ensure people using the service are fully safeguarded. Timescale for action 30/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Mountfield House DS0000066683.V362966.R01.S.doc Version 5.2 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. 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