Inspection on 25/10/06 for Edwina Mountbatten House

This inspection was carried out on 25th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Edwina Mountbatten House 22/10/08

Edwina Mountbatten House 29/11/05

Edwina Mountbatten House 18/11/04

Edwina Mountbatten House 07/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Edwina Mountbatten House Broadwater Road Romsey Hampshire SO51 8GH Lead Inspector Peter J McNeillie Unannounced Inspection 25th October 2006 09:00 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 Edwina Mountbatten House DS0000011778.V314275.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. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edwina Mountbatten House Address Broadwater Road Romsey Hampshire SO51 8GH 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) 01794 518317 Countess Mountbatten Memorial Trust Mrs Carol Robbins Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29/11/05 Brief Description of the Service: Edwina Mountbatten House is a registered charity run by a management board and registered manager. The home is purpose built and located near to Romsey town centre with easy access to local amenities and public transport and provides residential care for up to 18 older residents. Accommodation is provided on the ground and first floor, and is linked with a chair lift and equipped with a variety of aids and adaptations to allow residents to move around independently. Sixteen of the bedrooms are single and one is a double. Four of the single bedrooms have been fitted with en suite bathrooms. All residents are able to access the well-tended gardens to the front and side of the property. At the time of the visit charges varied between £300.79 and £354.55 per week. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took into account responses to a quality survey sent to residents by The Commission for Social Care Inspection about the quality of the service provided. Together with information received since the last inspection and the pre inspection questionnaire provided by the manager, no views were received from relatives or other professionals. This is the first inspection for the year 2006-2007. It is called a key inspection and will determine the frequency of visits/inspections hereafter. An unannounced inspection, was carried out on 25 October 2006 over a period of four hours, the Registered manager was on duty. The inspector spoke with a number of resident’s both individually and in groups, staff on duty and for a brief time the Chairperson of the management committee. Evidence was also gathered from a tour of the building, observations by the inspector, examining resident’s assessments/care plans, staff recruitment/ training records and equipment servicing records and comments by management/staff. What the service does well: What has improved since the last inspection? Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 6 There were no areas identified for improvement following the last inspection. 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. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 7 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 Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home has a system of assessing and identifying residents needs which ensures residents safety and their assessed needs can be met. EVIDENCE: A sample of four residents records were viewed, these confirmed that residents were only admitted on a planned basis following assessment of need and risk by the manager. External health care professionals would also be consulted if appropriate. Verbal confirmations by residents confirmed they were consulted and contributed to the assessment process but there was no written confirmation on files viewed to confirmed this. The manager gave a verbal undertaking she would address this shortcoming as soon as possible. Records also confirmed assessments of need and risk for all residents are reviewed on a regular basis and care plans adjusted if required. Respite care is not available in the home. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 9 Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The arrangements for planning care are clear ensuring that the health, personal care and medication needs of residents are met and their privacy and rights respected. EVIDENCE: Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 11 A sample of four residents records were viewed, four residents were spoken with individually and a number of residents in groups. Eleven responses were received from the satisfaction survey sent out by the Commision. All of the residents spoken with and responses received expressed total satisfaction with the care they were receiving and the manner in which it was delivered. They also confirmed they were consulted about the contents of their individual care plan and the assessments on which the plan was based but there was no written confirmation on files viewed to confirmed this. The manager gave a verbal undertaking she would address this shortcoming as soon as possible. Care plans, which were reviewed monthly-contained information on how identified needs including any special needs were to be met. Residents confirmed any personal care was given in private and staff always knocked and waited before entering their bedroom. The inspector observed this practice. Residents are able to make and receive telephone calls in private. Several residents had made arrangements to have their own telephone installed. Files seen and comments made by staff confirmed consultation with a range of external health care professionals such as doctors, district nurses, geriatricians, and continence advisors. Records viewed confirmed all resident’s drugs and medicines are administered and disposed of in accordance with the homes medication policy and procedure by trained staff and medication is stored are securely. Some residents were partially self-medicating following a risk assessment. Staff confirmed residents were free to choose their own GP and there are currently 9 doctors from 3 local practices visiting. Other personal services such as chiropodists, dentists and opticians are also provided. Assistance in accessing any service in the community was available. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The social activities, family contacts and the provision of varied and nutritious meals were well managed and reflected service users interests and choices. EVIDENCE: Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 13 Residents in praising the quality of their day-to-day lives were very complimentary about the homes staff, management and all other aspects of living in the home. From these comments and observations the inspector formed the view that routines were arranged to meet the needs of the residents. All residents confirmed they were able to exercise choice in respect of all aspects of their day-to-day lives including attending in house activities, which currently include bingo, armchair exercises, arts/ crafts and word games and trips. Religious services/communion is also held in house for all denominations of resident. Service users spoken to highlighted the quality, quantity, choice and presentation of food available. The inspector in checking the daily menu confirmed that there was a wide selection of food available and observed that the midday meal was well presented. Whilst there are set meal times advertised, the inspector confirmed with residents and the homes management these are flexible to ensure they meet resident’s needs and wishes At the time of the inspection no residents from minority ethnic groups with special dietary needs were resident. The inspector was informed that special diets and assistance with feeding (if required) are catered for. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home has clear policies and procedures in place which ensures residents are protected from abuse. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon. EVIDENCE: An in house Adult Protection policy/procedure that operates in tandem with the policy and procedure produced by Hampshire County Council designed to protect vulnerable residents from abuse was available as were records to confirm all staff had received training. Records viewed and staff spoken with confirmed they had received training in recognising abuse and demonstrated they knew what to do should they witness or suspect the abuse of any resident. The homes complaints procedure was which was also included in the service users guide included information on how to contact The Commission for Social Care Inspection (C.S.C.I) was seen as was a record of complaints. Residents spoken to stated they felt comfortable in raising any concerns they had with the homes management and confident any matters raised would be dealt with fairly and promptly but made it clear to the inspector “They did not have concerns” adding “Its like a five star hotel hear only better” a comment endorsed by other residents sitting nearby. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 15 Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19and 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home is provided for service users which meets their needs. EVIDENCE: A tour of the home for which a redecoration /refurbishment programme is in place indicated it was fit for its stated purpose, accessible, safe, well maintained meeting residents individual and collective needs. Furniture was comfortable and homely and in keeping with the décor. Residents commented how satisfied they were with the accommodation. All areas of the home were accessible to residents including the garden. The home was clean, hygienic and free from adverse odours. An infection control policy and procedure is in place. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all service users. EVIDENCE: Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 18 Residents were full of praise for their carers adding, “Lovely girls so pleasant” ”They are always cheerful and seem to know what to do” ” Appear well trained” “Always willing to help”. The care staff confirmed that they have access to good support, training, good and regular supervision. The staff rota, which was inspected, observations made during the inspection and residents comments indicated that sufficient care staff supported by management, domestic and kitchen staff were available to meet resident’s needs. The staffing records of four members of staff were viewed. Records indicated all staff are recruited and selected in accordance with a homes recruitment and selection policy and procedure which involves, the completion of an application form, an interview the signing of a rehabilitation of offenders declaration and satisfactory Criminal Bureau Records, Protection of Vulnerable Adult, medical and reference checks are carried out,. On commencement of employment all staff are subject to an in house induction course. Following induction and a probationary period all staff are expected to participate in National Vocational Qualification (N.V.Q.) training programme. Currently 60 of care staff are trained to at least N.V.Q. level 2. Five staff representing 41 are upgrading to N.V.Q.3 with a further three staff representing 25 are on a N.Q.2 course. In addition all staff are involved in training covering the administration of medication, food hygiene, moving and handling, first aid, health and safety, infection control and the protection of vulnerable adults, any other subjects as determined by residents needs. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.33,and 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The management of the home ensures the health, safety and welfare of residents and staff are promoted and the home is run in the best interests of the residents whose views about living in the home are formally sought. EVIDENCE: The service is well managed by the Registered manager who has obtained N.V.Q level 4. and she reports to a Management Committee. Comments received from residents and staff confirmed the manager is available and approachable and willing to listen to any suggestions that assist in meeting the changing needs of residents and improves the service. An open Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 20 door policy, encourage staff and residents to share any concerns or ideas that they have. There are clear lines of accountability within the home all staff were fully aware of there responsibilities. Staff and management confirmed staff meetings and one to one personal supervision takes place on a regular basis and this was confirmed by examining the records. Residents are consulted formally with evidence of regular residents’ meetings and the completion of a form at least annually which is normally when a review takes place. In discussion with the manager she stated the present quality evaluation process is due to be reviewed, progress will be evaluated at a future visit to the home. The home’s manager confirmed money was being held for some residents this was not checked on this occasion. The inspector observed no immediate obvious hazards to health and safety during the inspection. Cleaning materials and chemicals were securely stored and staff had access to information requiring to be held under COSHH regulations. Protective clothing and gloves were available to staff for use when necessary. The home has a health and safety policy, a copy of which is given to new staff. Staff spoken with showed an awareness of the need to attend to health and safety matters or to report these to the manager for action. The home has a laundry procedure and the industrial washing machine is capable of disinfecting soiled items. A sample of records relating to the servicing of equipment used within the home were viewed, all agreed with the information provided by the manager in the pre inspection report, this included the home’s fire and accident books and record of staff fire training. There were no records of a confidential nature on display in any of the public areas of the home. Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 Edwina Mountbatten House DS0000011778.V314275.R01.S.doc Version 5.2 Page 24 - 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!