Inspection on 04/08/04 for Mendip House

Care Home For Older PeopleMendip HouseWest Lane Chester le Street Co Durham DH2 3ASUnannounced Inspection4th August 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Mendip House Address Mendip House, West Lane, Chester le Street, Co Durham, DH2 3AS Email address Name of registered provider(s)/company (if applicable) Durham County Council Name of registered manager (if applicable) Mrs Vivien Mary Shingleton Type of registration Care Home No. of places registered (if applicable) 28 Tel No: 01913882514 Fax No: 01913882514Category(ies) of registration, with (number of places) Old age, not falling within any other category (28), Physical disability (8) Registration number B040000334 Date first registered 5th March 2003 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 11th May 2004 NO NO 07/01/04 If Yes refer to Part CMendip HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 34th August 2004 09:45 am Mr Stephen EllisID Code073275Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Vivien ShingletonMendip HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementMendip HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Mendip House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Mendip HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Mendip House is a long established care home for older people, provided by Durham County Councils Social Services Department. It provides 28 care beds, all in single rooms. The twostorey building has generous communal space (lounges and dining room) and is generally well equipped for the assessed needs of its service users. Externally, there is a garden and car parking spaces. In 2004, the care home developed an intermediate care unit for 8 people with physical disabilities over the age of 55 years. This unit is not currently operational, but its intended use is the rehabilitation of service users who are admitted for short stays so that an intensive rehabilitation programme can be applied. The remaining 20 beds are for either permanent or respite care. It is anticipated that future admissions to the care home will be either for respite or intermediate care.Mendip HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced inspection took place on 4th August 2004. It found that the vast majority of National Minimum Standards had been met, 2 had been partially met, and 5 had been exceeded. The overall standard of care was good. Comments were received from a cross section of service users, expressing satisfaction with the services and facilities provided. Choice of Home (Standards 1-6) 5 of the 5 standards assessed were met, with one being exceeded. There are good arrangements for enabling prospective service users to make an informed choice concerning admission to Mendip House. The homes statement of purpose and service users guide are both detailed and well presented. They are available in various formats. Prospective service users are only admitted if the home is able to meet their assessed needs. Written assessments of need are comprehensive and detailed. Trial stays and introductory visits are encouraged. All placements are subject to review, usually within 6 weeks of admission. `Sitting scales are desirable. Health and Personal Care (Standards 7-11) 5 of the 5 standards assessed were met Good arrangements were in place for meeting the health and personal care needs of service users. Care plans are in the process of being transposed to new, improved formats designed by County Durham Care and these were comprehensive. Daily Life and Social Activities (Standards 12-15) 4 of the 4 standards assessed were met, with two being exceeded. Good arrangements are in place with regard to daily life and social activities. A very good programme of social and recreational activities is in operation and service users spoke particularly highly about this aspect of provision. Visitors are welcomed and there are good links with the local community. Catering standards are particularly high.Mendip HousePage 6 Complaints and Protection (Standards 16-18) 3 of the 3 standards assessed were met The homes policies, procedures and practice conform to National Minimum Standards. Staff training addresses adult protection issues. Service users expressed confidence in discussing with staff any issue of concern, or making a complaint. Environment (Standards 19-26) 8 of the 8 standards assessed were met, with two being exceeded. Environmental standards comply with National Minimum Standards. This home is well maintained, well decorated and well equipped. Improvements, carried out since the last inspection, include the fitting of additional electrical sockets and thermostatic control valves to radiators, in bedrooms. A new `dignity shower has been installed, plus an electric ceiling hoist in another bathroom. There are a range of attractive bedrooms, communal rooms, bathrooms and toilets. Communal space exceeds National Minimum Standards. Externally, the grounds are well maintained, with attractive borders, tubs and hanging baskets, plus garden seating. Staffing (Standards 27-30) 4 of the 4 standards assessed were met. The home is adequately staffed with people who are experienced and competent to care for older residents. 56 of members of the care staff team have attained NVQ level 2 or above, and there are other staff members registered as candidates for the award. A good staff development programme is in operation. The home has achieved the Investor In People and Charter Mark awards. Management and Administration (Standards 31-38) 6 of the 8 standards assessed were met. Arrangements for the management and administration of the home are sound. The manager is working towards the registered managers qualification and expects to achieve it within the specified time limit of 2005. Staff supervision has commenced but the frequency will need to be increased to satisfy National Minimum Standards. Reports made under regulation 26 will need to be sent to the CSCI.Mendip HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Mendip HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 18 OP36 Members of care staff are required to have at least 6 supervision sessions per year. Reports of visits made under this regulation must be sent to the CSCI, in addition to the other designated parties. 01/10/04226OP3301/10/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 OP4 OP31 Sitting scales are desirable so that service users weights can be easily and reliably recorded. It is expected that the registered manager will achieve NVQ level 4 in management and care, or equivalent, by 2005.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Mendip HousePage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES YES NO NO YES YES YES YES YES YES YES NO NO YES NO YES 13 0 0 YES YES YES YES 16 0 04/08/04 09:45 5Mendip HousePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Mendip HousePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 432.32 To (£) 432.32Any charges for extras If yes, please state what the extras are:YESHAIRDRESSING, TOILETRIES, NEWSPAPERS 4 Key findings/Evidence Standard met? The standard is exceeded. A very good statement of purpose and separate service users guide has been produced. These documents are written in plain language, are well laid out and are accessible. They are available in various versions, including large-print, Braille and audio.Mendip HousePage 12 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The standard is met. A comprehensive statement is provided, for example in the service users guide.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The standard is met. Comprehensive assessments of need support each admission, except in exceptional cases of emergency. It is the explicit policy of the home to ensure that even in such exceptional cases, full written assessments of need are obtained within 5 days.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The standard is met. Facilities and services provided are as described in the homes statement of purpose and service users guide. These are suitable and sufficient to meet the assessed needs of service users. Recently, specialist shower and hoist equipment have been installed. However, sitting scales would be desirable at this home so that service users with mobility problems can be weighed easily and reliably. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The standard is met. Prospective service users are always invited to visit the home and to have a trial placement before deciding whether to stay. Unplanned admissions are avoided where possible. Any such emergency admissions result in written assessments of need being completed and shared with the home within 5 working days. Latterly, the homes policy on admissions has changed: people will be admitted only for respite or intermediate care (rehabilitation), both of which are short stays.Mendip HousePage 13 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Intermediate care is not yet provided, although it is anticipated that it will be within the next 12 months.Mendip HousePage 14 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The standard is met. Detailed plans of care are based on comprehensive assessments of need. The home is planning to introduce revised and improved formats for such plans of care in the near future, having piloted them over the past year. The home involves the service user (and/or representative) in the care planning and review processes and obtains signatures wherever appropriate. The home is refining the care planning and review processes. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 2 13 Key findings/Evidence Standard met? The standard is met. Information from records confirmed comments received from service users, staff and management that service users health care needs are well addressed and that there are good health care assessments and treatments provided for service users. The home continues to try to ensure that no service user attends external health care appointments unescorted, especially in the case of emergency treatments.Mendip HousePage 15 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The standard is met. Practice conforms to national minimum standards. Members of care staff responsible for medicines have undergone `safe handling of medicines training, that is training that is regarded as being `accredited. Policies and procedures with regard to medication are sound. In particular, good procedures are in place for the management of controlled drugs.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The standard is met. Service users feel they are treated with respect and their right to privacy is upheld. Comments received from service users were positive and complimentary about care practice at the home. Privacy and dignity are core values addressed in the homes statement of purpose and in staff training and development programmes. Service users demeanour and appearance reflected this view. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The standard is met. Practice accords with national minimum standards. Service users wishes with regard to death and funeral arrangements are identified and recorded. Service users, their families and friends are treated with great care and sensitivity in the last days of the service users life, when death is anticipated.Mendip HousePage 16 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 4 Key findings/Evidence Standard met? The standard is exceeded. Comments received from service users and staff confirmed documentary evidence that a full and varied programme of social and recreational activities is provided. Service users expressed much satisfaction with their lifestyle at Mendip House. Their individuality was respected and they were encouraged to exercise choice in their daily lives and personal routines. Activities available and participated in included visits to local theatres, outings to places of interest and meals out, shopping trips, baking, bingo, sing-alongs, dominoes, newspapers and magazines, reading books (e.g. large print library service to the home), knitting, receiving visiting entertainers, exercise sessions, recall and reminiscence, visits from `Create (an organisation dedicated to providing a range of relevant and meaningful activities for service users in care homes), television and local walks. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? The standard is met. Service users confirmed that they are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with their preferences.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? The standard is met. Service users individuality is respected and the home tries to promote independence wherever appropriate. Service users are regularly consulted about choices and preferences, both individually and collectively.Mendip HousePage 17 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 4 Key findings/Evidence Standard met? The minimum standard is exceeded. Mendip House is to be congratulated on maintaining a high standard of catering. A very good choice of menu is provided throughout the day. Alternatives are also supplied. Care is taken to offer little extras such as an attractive selection of sweets and cakes. Meals are served using tureens for vegetables, helping to promote choice. Adapted cutlery and crockery is provided where appropriate. Meals are attractively presented. The dining room has a welcoming ambience due in part to the décor and table settings that help make dining a pleasurable experience. Linen napkins are used. A variety of drinks are available including water and tea. Special diets are supplied if required. A cooked breakfast is available each day. Special events such as birthdays are celebrated with a cake. Service users spoke very highly of the standard of catering and clearly enjoyed this aspect of daily life at Mendip House.Mendip HousePage 18 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 100 3 Key findings/Evidence Standard met? The standard is met. There is a clear and accessible complaints procedure that is included in the service users guide. Complaints are welcomed by the homes management, along with comments and compliments, as part of its quality assurance policy. Service users commented that they would have no hesitation in approaching the manager or staff with any matter of concern. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The standard is met. Service users are encouraged to participate in the civic process, including voting in political elections, unless they prefer not to be involved. Service users legal rights are respected and independent advocacy can be supplied if requested.Mendip HousePage 19 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The standard is met. The homes policies and procedures are designed to protect service users and promote their welfare. These were consistent themes found throughout the inspection, reinforced for example in staff training and the homes statement of purpose. Comments received from service users and staff confirmed these observations.Mendip HousePage 20 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 4 Key findings/Evidence Standard met? The standard is exceeded. The home is well maintained and it is furnished and decorated to a high standard. Replacement of the first floor shower has been achieved since the last inspection with a high quality `dignity shower. Also, the home has fitted thermostatic control valves to radiators in bedrooms so that the temperatures of radiators can be individually controlled, plus additional electrical sockets in bedrooms, so that there are at least two twin sockets in each room. An electric ceiling hoist has been installed in one bathroom. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 4 Key findings/Evidence Standard met? The standard is well met. Service users have access to safe and comfortable indoor and outdoor communal facilities. There are two lounges on the ground floor plus a spacious dining room. Upstairs, there is a lounge of good size, plus another separate lounge for smokers. The lounges and dining room are attractively decorated and furnished with comfortable and homely items in place. Much effort has been expended on trying to promote good standards of provision, including the fitting of window drapes and good quality floor covering. There are benches supplied in sheltered places externally so that service users may enjoy sitting outside, if desired.Mendip HousePage 21 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? The standard is met. There are 4 bathrooms and one shower room. A new `dignity shower has been installed since the last inspection and, in another bathroom, an electric ceiling hoist has been fitted. There are no en suite facilities, but toilets (10) are well distributed about the home. Toilets have paper towels and liquid soap provided in dispensers fitted to the walls. Service users were satisfied with the standard of provision. Assisted bathing is provided in at least two bathrooms. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The standard is met. The home is well supplied with disability equipment, aids and adaptations. For example, new hoists have been acquired, including a specialist, electric ceiling hoist, and the old shower has been replaced by a high quality `dignity shower. Specialist cutlery is provided where appropriate.Mendip HousePage 22 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 28 0 0 0 21 76 0 0 03 Key findings/Evidence Standard met? The standard is met. Bedrooms are of acceptable size, with 21 being in excess of 10 sq m and six of these are in excess of 12 sq m. Seven are slightly less than 10 sq m. The bedroom sizes satisfy the revised national minimum standards (June 2003). All bedrooms are singles.Mendip HousePage 23 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? The standard is met. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users were pleased with the quality of their rooms.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The standard is met. Service users live in safe, comfortable surroundings. Heating in service users own rooms can now be controlled individually, following the installation of thermostatic control valves to each radiator earlier this year. Also, since the last inspection, the home has increased the number of electrical sockets in bedrooms, so that there are at least two twin sockets in each room, appropriately distributed. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The standard is met. The home was found to be clean, pleasant and hygienic. Liquid soap and paper towels are provided in communal toilets. The home has full written policies on infection control and members of care staff have undergone relevant training.Mendip HousePage 24 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 2 X 0 needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 10 14 475 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 494 0 0 00 16 83 Key findings/Evidence Standard met? The standard is met. The number of care hours provided and the pattern of deployment are in accordance with the assessed needs of current service users. The total number of care hours provided each week assumes that only 50 of the total hours provided by the residential supervisors is given over to direct care. The staffing calculation is based on Department of Health guidance. Typically, for 26 service users accommodated, there are 3 care assistants and one residential supervisor on duty during the day (07:00 ­ 22:00) and 2 care assistants at night. The registered manager is supernumerary. There is a part-time administrator (12.5 hours), one maintenance person, 2 catering staff, 2 domestic staff and 2 part-time domestic staff. Mendip House Page 25 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 9 56 3 Key findings/Evidence Standard met? The standard is met. The home has achieved the minimum standard and two additional members of the care staff team are currently working towards the qualification. Two members of care staff have NVQ level 3 (included in the figure of `9 above). Well done!Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The standard is met. Service users are supported and protected by the homes recruitment policy and practice. All required checks on prospective employees are carried out, including Criminal Record Bureau checks and employment references. Individual, staff personnel files are maintained. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The standard is met. There is evidence of a staff training and development programme that covers induction and foundation training plus additional courses and NVQ in care. This programme includes `No Secrets training, Safe Handling of Medicines, Infection Control, `Intermediate Care training, Customer Care and Core Values, Moving and Handling, and Fire Safety. Several staff are engaged in NVQ training and assessment, as candidates and as assessors.Mendip HousePage 26 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The standard is nearly met. The managers qualifications include RMN, CSS (specialist subject: management) and NVQ level 3 in management. The manager has undertaken periodic training to update her knowledge, skills and competence and has substantial experience in a senior management capacity within the care home setting. However, the registered manager intends to achieve NVQ level 4 in management and care, or equivalent, by 2005, in order to comply fully with the National Minimum Standard. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The standard is well met. There is substantial evidence to confirm that the management ethos and approach promotes consultation and inclusion, and provides clear leadership, with a strong commitment to the values and principles underpinning good social care practice. Management planning and practice encourage innovation, creativity and development within the home, among staff and service users alike. Comments received from service users and staff were very positive about this aspect of Mendip House.Mendip HousePage 27 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The standard is met. There is substantial evidence to confirm that the home is run in the best interests of service uses. There is continuous self-monitoring of performance, which includes the use of service user surveys and Residents Committee meetings, and the home has achieved the Investor In People and Charter Mark awards, both of which are indicative of quality assurance systems. Mendip House is also taking part in County Durham Cares Aiming for Excellence programme. In addition, it has been piloting a new care-planning tool, being introduced by County Durham Care, based on the principles of holistic care, with attention being focused on a detailed assessment of personal care needs. However, reports of visits made under regulation 26 are not always being received by the CSCI each month and the home will need to address this issue. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? The standard is met. Service users are safeguarded by the accounting and financial procedures of the home. Policies and practices accord with national minimum standards. There is a business and financial plan for the establishment that is reviewed at least annually.Mendip HousePage 28 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders 0 1 03 Key findings/Evidence Standard met? The standard is met. Service users financial interests are safeguarded by, for example, the provision of individual Post Office accounts and the maintenance of comprehensive records of transactions. In some cases, service users control their own monies directly; in others, relatives may help; but, where necessary, Mendip House will assist service users directly to maintain their own monies. Recording of transactions in which the home is involved is detailed and subject to close scrutiny.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? The standard is nearly met. The home has introduced a policy to ensure that members of care staff have formal supervision at least 6 times per year. Care staff and management confirmed that formal supervision has commenced, but the required frequency of sessions may not be achieved this year. This has been due in part to preparations for the introduction of intermediate care and the absence of a full complement of residential supervisors. Records of staff supervision are maintained in staff files. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? The standard is met. An examination of a sample of records confirmed that the homes practice conforms to National Minimum Standards. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures.Mendip HousePage 29 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The standard is met. There is evidence that the registered manager ensures health and safety via safe working practices. These include staff training, maintenance of a safe environment, written risk assessments and the posting of safety procedures.Mendip HousePage 30 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateStephen Ellis John Williamson 13th September 2004Signature Signature SignatureMendip HousePage 31 Public reports It should be noted that all CSCI inspection reports are public documents.Mendip HousePage 32 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 4th August 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers comments and an action plan were not submitted to the Area Office.Mendip HousePage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 16 august 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNONOYESOther: enter details here Mendip HousePage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Teresa Brown of County Durham Care confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Responsible Individual Teresa BrownPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Mendip HousePage 35 Mendip House / 4th August 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000031195.V179529.R01© This report may only be used in its entirety. 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