Care Home: Western Mount Lodge

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What the care home does well The proprietors ensured that the home was well maintained and comfortable. The staff group was stable, with some staff having worked at the home in excess of ten years, which helped to provide consistency of care and a family atmosphere. Care plans were well written and gave clear instructions to staff on how to deal with mental health needs and promote independence and choice. Health services were called in when required and specialist help and advice was sought as necessary. Care needs were reviewed regularly with a health professional. This ensured that health needs were met and healthy living promoted. Feedback on the surveys was generally positive with comments from visiting professionals describing the home as `excellent` and another stating that the home were `able to manage a crisis well` and that staff were `excellent and provide understanding and skilled intervention`; staff surveys were generally positive about working at the home and one survey stated that the managers were supportive and commented `well done to the management` and a relatives` survey said they were `very pleased` with the service provided. Meals were well managed and people enjoyed them. There was choice and variety and an emphasis on healthy eating. Quality assurance processes were well established and the providers had provided detailed and comprehensive information on their annual quality assurance assessment that demonstrated how they intended to improve the service. What has improved since the last inspection? Staff had undertaken training in end of life care and completed the `Liverpool Care Pathway` training. Medication refrigerator temperatures were being recorded on a daily basis when the refrigerator was in use to ensure safe storage of medicines. Refurbishment was an ongoing process and included new armchairs, landscaping of the outside area, re-decoration of the office and kitchen, upgrading of laundry appliances and new carpets in bedrooms. People living in the home were able to express the views and opinions more through regular meetings. CARE HOME ADULTS 18-65 Western Mount Lodge 109 Radbourne Street Derby DE22 3BW Lead Inspector Janet Morrow Unannounced Inspection 23rd July 2008 11:00 Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Western Mount Lodge Address 109 Radbourne Street Derby DE22 3BW 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) 01332 343954 peter.steventon@ntlworld.com Miss J Brownhill Mrs J Brownhill, Miss L Brownhill, Mr P & Mrs B Steventon Mrs Mary Bernadette Steventon Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th June 2007 Brief Description of the Service: Western Mount Lodge is a detached house, which has been adapted and extended to provide personal and nursing care for up to 18 people of either sex aged 18 years and over with mental health needs. Residents are assisted to develop daily living and social skills, and work towards a more independent lifestyle. The home is in close proximity to local shops, facilities and a bus route and is 3 miles from Derby city centre. The home has 8 single and 4 shared bedrooms on the ground and first floor, 4 rooms have en suite facilities. Access to the first floor is by stairs and a passenger lift. The home has 2 lounges and a dining room on the ground floor. People who choose to smoke are required to smoke outside in a designated covered area. Written information provided in August 2008 stated that fees ranged from £455 - £945 per week. The most recent inspection report is on display in the home’s entrance area. Western Mount Lodge DS0000002151.V369001.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 inspection visit was unannounced and took place over one day for 4.75 hours. Care records and staff records were examined. Four members of staff, six people living at the home and the provider were spoken with. The manager was not on duty at the time of the inspection visit. Two visiting professionals were contacted by telephone following the inspection visit. Eleven surveys were received in total prior to the inspection visit; four from people living in the home, two from relatives, three from staff and two from visiting professionals. A partial tour of the building was undertaken. Written information in the form of an annual quality assurance assessment was provided by the home prior to the inspection and informed the inspection process. What the service does well: The proprietors ensured that the home was well maintained and comfortable. The staff group was stable, with some staff having worked at the home in excess of ten years, which helped to provide consistency of care and a family atmosphere. Care plans were well written and gave clear instructions to staff on how to deal with mental health needs and promote independence and choice. Health services were called in when required and specialist help and advice was sought as necessary. Care needs were reviewed regularly with a health professional. This ensured that health needs were met and healthy living promoted. Feedback on the surveys was generally positive with comments from visiting professionals describing the home as ‘excellent’ and another stating that the home were ‘able to manage a crisis well’ and that staff were ‘excellent and provide understanding and skilled intervention’; staff surveys were generally positive about working at the home and one survey stated that the managers were supportive and commented ‘well done to the management’ and a relatives’ survey said they were ‘very pleased’ with the service provided. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 6 Meals were well managed and people enjoyed them. There was choice and variety and an emphasis on healthy eating. Quality assurance processes were well established and the providers had provided detailed and comprehensive information on their annual quality assurance assessment that demonstrated how they intended to improve the service. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 7 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. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient admission information is available to ensure that the home is suitable and can meet the needs of people living there. EVIDENCE: Two peoples’ care files were examined and both had an assessment in place. Information from external professionals was available and the background information compiled by the home was detailed and gave a clear picture of individual needs. Three of the four surveys received from people living in the home responded that they received enough information before deciding to move in. The annual quality assurance assessment stated that the assessment process ensured that staff spend time ‘gathering pertinent information from interested parties & visiting & assessing prospective residents - for instance in hospital or at their place of residence’. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Individual care plans ensure that consistent patterns of support are given and that independence is maintained. EVIDENCE: Two peoples’ care files were examined and showed that a comprehensive care plan was in place that demonstrated how individual needs would be met. They were detailed and gave clear information to staff on how to deal with specific areas of need. Mental health issues were particularly well covered, giving specific instructions on how to approach and deal with particular issues. For example, there were strategies in place instructing staff what to do if medication was refused, in relation to neglect of personal hygiene and how to deal with challenging behaviour. They were easy to follow and legible. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 11 Risk assessments were available in individual care files that showed how identified risks were minimised. For example, on one file, a tissue viability risk assessment indicated a need for this to be undertaken on a monthly basis and examination of the record showed that this was occurring and on another file nutrition was an issue and the there were strategies in place to ensure this was addressed. There were also crisis plans in place to cover identified areas of need that had the potential to impact negatively on health. Both care plans had been reviewed and one had been signed as agreed by the person involved. Staff spoken with stated they understood what care was required and were clear about what they needed to do. One visiting professional contacted after the inspection visit stated that the person they were involved with had ‘come a long way’ since their admission to the home and another said they ‘do what is stated in the care plan’ and described the home as ‘efficient and effective’. There was evidence from general observation and discussion with people living in the home and staff that they were involved in decisions about their life and able to make decisions, with assistance, as required. Those people spoken with were able to pursue their own interests. A survey received from a visiting professional commented that the home provided ‘non-judgemental person centred care aiming to promote the person’s strengths, abilities and independence’. All four surveys from people living in the home responded that the staff listened and acted on what they said and one commented ‘they do mostly’. The home had also convened regular meetings for people in the home and the records of these were available and showed that people actively contributed and were assisted to make decisions on their daily lives and suggested improvements to the home. Advocacy services were well used and the annual quality assurance assessment stated that people knew how to contact the advocacy service and were assisted & encouraged to do so. Advocacy service details were displayed on the notice board and were specifically mentioned in the home newsletter. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ quality of life and lifestyle choices are enhanced by well-managed meals, contacts with the community and activities. EVIDENCE: People living at the home were observed to have their own routines as far as possible, with some choosing to go out and others participating in hobbies of their choice such as knitting and gardening. There were photographs on display that showed a range of social activities taking place such as baking, painting and gardening and one person spoken with said that they ‘went out more’. Two of the four surveys received from people living in the home responded that there were ‘always’ activities available, one responded that Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 13 there ‘usually’ were and one listed jewellery making, going out to groups and outings as options available. The written information supplied by the home stated that people attended community groups, college courses and external rehabilitation placements. Spiritual needs were also catered for and several people chose to attend the local church. The local Christian minister called at the home during the inspection visit to give communion. The menu was examined and showed that healthy options were available. The written information supplied by the home stated that healthy options had been introduced and fruit was now available at breakfast. It also stated that a varied menu was on offer which reflected the likes & dislikes of people living in the home and that meals were a regular agenda item at meetings. There were two options avaiable at lunchtime on the day of the inspection visit. All people spoken with during the inspeciton visit described the food as ‘good’ and survey feedback was positive; one survey described them as ‘fairly good’ and another repsonded that they ‘always’ liked the meals and two that they ‘usually’ did. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ health and personal care needs are well managed, which ensures that good health is maintained. EVIDENCE: Two peoples’ care files were examined and showed that access to health professionals was made available. There were records available that showed visits to dentists, opticians and General Practitioners took place. These records also showed that attention was paid to nutritional needs and skin condition needs with risk assessments for nutrition and tissue viability being undertaken and having appropriate interventions detailed. Weight was also recorded on monthly basis on the two files examined. There were regular reviews of care held with other health professionals that ensured changing needs were addressed. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 15 The four surveys received from people living at the home stated that they ‘always’ or ‘usually’ received the medical support they needed and both relatives’ surveys received responded that they were ‘always’ kept up to date with important issues affecting their relative and that that the expected care and support was ‘always’ given. Two staff surveys responded that they were ‘usually’ given up to date information on peoples’ needs and one responded that they were ‘always’ given it. Both surveys received from visiting professionals responded that individuals’ health care needs were ‘always’ met and one survey commented that staff ‘will adapt care strategies and seek support until the issues/needs have been met/resolved’. One visiting professional described the home as ‘very good’ and that they were ‘meeting complex needs’. It was observed that personal support was offered sensitively and people spoken with stated that they found staff helpful. General observation showed that there were warm relationships between staff and people living in the home. There was a designated member of staff who was continence link nurse and kept up to date with developments in promoting continence. A random sample of five medication administration record (MAR) charts was examined to check for accuracy of recording. These were found to be in generally good order with amount of medication received recorded, two signatures where charts were handwritten and identity information was available. However, although most charts seen were signed accurately, there were two gaps for one medication on one chart where a medication should have been given and no code to explain why it was not given. The nurse in charge stated that the medicine had been given but the chart had not been signed. Two peoples’ charts were then examined in more detail and were completed accurately, with signatures or codes. The nurse in charge stated that there were no controlled drugs currently in use but there was a register available to record them if necessary and secure storage was provided. The medication refrigerator was not in use at the time of the visit but there were records available that showed the temperatures had been recorded on a daily basis when in use and it was recorded when it was switched off. Stocks of medication were good and within expiry dates. There was a copy of the Royal Pharmaceutical Society Guidelines available but it was not the most up to date version. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clear complaints procedure and comprehensive safeguarding information and procedures ensured that people in the home were listened to and safeguarded. EVIDENCE: The complaints procedure was on display in the home and stated that complaints would be dealt with within twenty-eight days. The written information supplied by the home stated that six complaints had been received at the home during the last twelve months and all had been responded to within twenty-eight days. There had been no complaints received at the office of the Commission for Social Care Inspection since the previous inspection in June 2007. The complaints record was examined and showed that complaints were responded to thoroughly and indicated whether or not the complainant was satisfied with the outcome. The written information supplied by the home stated that ‘our intent is that all complaints are handled in a positive manner.’ All four surveys received from people living in the home stated that they knew how to make a complaint and one relatives’ survey stated that they knew. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 17 However, one relatives’ survey responded that they did not know how to complain. The previous inspection report of June 2007 indicated that a copy of Derby and Derbyshire Local Authority Social Services safeguarding procedures, information on how to refer to the Protection of Vulnerable Adults (POVA) list and a copy of the Department of Health ‘No Secrets’ guidance was available. The written information supplied by the home stated that there had been no incidents of abuse in the last twelve months. Staff spoken with were aware of their responsibility to report any suspicions of abuse and training records showed that safeguarding training had occurred in February 2008. There were financial procedures in place to ensure that peoples’ personal money was dealt with properly and cash was stored securely. However, on the day of the inspection visit it was not possible to check that individual records corresponded with the money held. This was because access to the cash was not available due to the manager being on leave and being the only key holder for the secure storage. Peoples’ access to their personal money in the absence of the manager was discussed with the provider, who stated that individuals discussed their cash needs with the manager prior to her leave and sufficient was held in petty cash to ensure no one went without access to their money. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is furnished and maintained to a high standard, which ensures homely and spacious facilities for people to safely enjoy. EVIDENCE: The home was well maintained and furnishings and fittings were of good quality. The written information supplied prior to the inspection stated that some of the refurbishment included new armchairs, landscaping of the outside area, re-decoration of the office and kitchen, upgrading of laundry appliances and new carpets in bedrooms. The home was clean, tidy and odour free. There was an outside designated smoking space, a summerhouse, for those people wishing to smoke. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 19 The laundry was neat and tidy and information was available on infection control procedures. Staff spoken with knew how to control the spread of infection and confirmed they had received training in this area. They also stated there was a plentiful supply of protective equipment such as gloves and aprons. The written information supplied by the home stated that the home was using the ‘Essential Steps’ guidance from the Department of Health. Three of the four surveys received from people living in the home responded that the home was ‘always’ fresh and clean and one commented that ‘a lot of time has been devoted by certain staff to cleaning’. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in staff recruitment procedures had the potential to compromise peoples’ safety. EVIDENCE: Examination of the staff rota for 21st – 27th July 2008 showed that there was one trained nurse on duty at all times and two care staff on duty in the morning and afternoon and one in the evening. The provider stated that there were no issues currently with staffing and the written information provided by the home stated that the staff group was stable and many had been employed long term. Staff spoken with confirmed that there were no staffing issues and that agency staff were used when necessary if there were shortages due to sickness or leave. Three of the four surveys received from people living in the home responded that there were ‘always’ staff available when needed. Two of the Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 21 three staff surveys received responded that there were ‘usually’ enough staff and one responded that there were ‘always’ enough staff. Staff confirmed in discussion, and certificates verified, that they had undertaken mandatory health and safety training as well as in other areas applicable to the job, such as epilepsy, end of life care and the Liverpool Care Pathway. However, not all staff had undergone training on how to deal with challenging behaviour and staff spoken with thought this was an essential skill to have in their work. The written information supplied by the home stated that four of nine care staff had achieved a National Vocational Qualification (NVQ) at level 2 or above and two were working towards it. This meant the home was meeting the target of having 50 of care staff with an NVQ2. All three staff surveys received responded that they ‘usually’ had the right support, knowledge and experience to meet the needs of people living in the home. One commented that the home was ‘very keen on having staff do their NVQ training’. Regular supervision took place, which was confirmed on the written information supplied by the home and in discussion with staff. Staff files showed that this occurred approximately two monthly. One staff member commented in discussion that other staff were ‘really helpful’ and that the manager was always available to answer queries. One staff survey commented that the home was ‘one of the best’ in providing support. Two staff files were examined and showed that all the information required by Schedule 2 of the Care Homes Regulations 2001 was in place, including identity information, Criminal Record Bureau (CRB) checks, verification of license to practise for qualified staff and two written references. However, Protection of Vulnerable Adults (POVA) First checks were not being obtained pending arrival of a full CRB disclosure. Although both files contained a POVA First check, these were both dated after the start of employment. This was raised as an issue at the previous inspection in June 2007 and failure to obtain these checks prior to the commencement of employment does not ensure the safety of people living in the home. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and ensures the health and safety of staff and people living there. EVIDENCE: The manager was registered with the Commission for Social Care Inspection and was qualified and experienced, having run the home since 1993. The owners were also available regularly and operated an ‘on call’ system twentyfour hours per day. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 23 Quality assurance processes had been developed and the home had a number of ways of collating the views of people living in the home and auditing the quality of care. This included visits by the proprietors, audits of care files and surveys. The written information supplied by the home stated that meetings for people living in the home were also now a regular occurrence and photographs of the meetings and discussions with participants confirmed this. However, there were no staff meetings held although staff spoken with thought that these would be useful. A survey had taken place in August 2007 and the results of these had been analysed and were generally positive. One had commented that ‘you give a good service’. Discussion with the proprietor demonstrated that the home was clear in how it intended to improve and the written information supplied was detailed and gave clear examples of what action was needed improve the service. For example, it stated that surveys were to be revised to ensure suggestions for improvement were made and that a health and safety compliance audit was to be developed. The detail provided in the annual quality assurance assessment showed that the providers had clearly taken time and trouble to address the quality of the service provided and they are therefore commended for their efforts. Staff interviewed confirmed that health and safety training was undertaken in food hygiene, moving and handling, infection control and fire safety and this was verified in their files. The written information also confirmed that maintenance checks were undertaken regularly; for example fire equipment and alarms had been tested in October 2007, hoists and adaptations had been checked in December 2007, gas appliances in January 2008 and the lift in October 2007. However, portable electrical appliances checks were stated as last being undertaken in September 2006 and were therefore overdue for an annual check. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 4 X X 3 X Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (4) Requirement Staff administering medication must always ensure that they sign the medication administration record (MAR) charts correctly. Protection of Vulnerable Adults (POVA) First checks must be in place if the home intends to have staff working in the home prior to a receiving a full Criminal Record Bureau (CRB) disclosure. This is to ensure the safety of people living in the home. Timescale for action 01/09/08 2. YA34 19 (1) (b) (i) & Schedule 2 01/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations An up to date copy of the Royal Pharmaceutical Society Guidelines should be obtained. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 26 2. 3. 4. 5. YA22 YA35 YA39 YA42 The home should ensure that all visitors to the home know how to make a complaint. All staff should undertake training on dealing with challenging behaviour. Consideration should be given to having staff meetings to assist with the quality assurance process. Portable electrical appliances should be checked on an annual basis. Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Western Mount Lodge DS0000002151.V369001.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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