Inspection on 09/08/05 for Mon Choisy

This inspection was carried out on 9th August 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mon Choisy 24/07/09

Mon Choisy 24/07/07

Mon Choisy 16/07/07

Mon Choisy 22/06/06

Mon Choisy 21/02/06

Mon Choisy 23/11/04

Mon Choisy 29/06/04

Mon Choisy 12/02/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mon Choisy 128 Kennington Road Kennington Oxford OX1 5PE Lead Inspector Andy McGuckin Unannounced 09 August 2005 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 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. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mon Choisy Address 128 Kennington Road, Kennington, Oxford, OX1 5PE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01865 739223 Mrs Ellen Audit Mrs Ellen Audit Care Home 28 Category(ies) of OP; DE(E) registration, with number of places Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The total number of persons that may be accommodated at any one time must not exceed 28. Date of last inspection 23 November 2004 Brief Description of the Service: The home provides 24 hour support for service users and accesses appropriate external support to maintain the health and welfare of those accommodated. The home endeavours to meet the assessed needs of the service users in a clear, open and person-centred manner. The home does not provide nursing care but has access to all community health care professionals. Mon Choisy shares a management structure and policies and procedures with its sister home, Kirlena House. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place early on a Tuesday morning. The purpose of the timing was to assess the morning routine of the residents. On arrival the inspector (who was wearing an identity badge) accessed the main house via the kitchen, passing two staff members on the way. The inspector was not challenged until inside the home when a senior member on the oncoming shift asked for clarification of who the inspector was and what he wanted. After introduction the inspector followed the member of staff to the office. At this time no staff from the nightshift had been identified. After approximately ten minutes the inspector was introduced to the senior carer who had been on night shift. During the inspection the dining room smelt strongly of urine. Staff were not in evidence to attend to the residents at the times the inspector looked into the dining room between 7.50 and 8.10am. Care, when given, was observed to be courteous and in a dignified manner. The inspector sat in on two staff handovers, both of which were conducted in a professional manner. The inspector observed medication being given and did spot checks on the recording and distribution of medication. Medication was found to be stored in a fridge along with resident’s food and a requirement was made to provide separate refrigerated space for medicines. A tour of the building took place - no areas of concern were found regarding health and safety issues. The inspector is of the opinion that the lack of carpet in the communal areas and in many of the bedrooms, combined with metal framed beds, is very clinical in nature and detracts from the homely environment found in many other residential homes. Residents’ files were inspected and found to be satisfactory. Staff files were inspected and found to contain omissions or inappropriate documentation. A fuller explanation can be found in the main body of the report. What the service does well: What has improved since the last inspection? Some improvements have been made as to how the home records and presents information. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 6 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. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4, 5, 6. The home provides information on which prospective service users can make a decision. Prospective service users are assessed prior to moving into the home. EVIDENCE: The inspector was shown the home’s Statement of Purpose and Service User guide. These documents outline what the home can and cannot provide. They are written in plain English and are easily understood. Each resident has a written contract/terms and conditions. The residents’ contract is signed by the resident or his/her advocate. The manager or provider assesses all prospective residents prior to admission. Admission is dependent on a mutual agreement that the home can meet the resident’s needs. Where it is discovered that the home is not meeting the resident’s needs, a review meeting is held involving all interested professionals, family or advocate. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 9 Prospective service users are encouraged to visit the home prior to admission but, due to the care characteristics of many of the residents, this is not always feasible. Friends and relatives are encouraged to maintain contact with residents and prior feedback from relatives indicated that they are made welcome when visiting and can visit at all reasonable times. An individual care plan is drawn up stating what the residents care needs are and stating how the home will meet them. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10, 11. Residents are respected and their dignity is being maintained. Medication is recorded and distributed appropriately. EVIDENCE: Evidence was found at the inspection, by reading residents’ files and in sitting in at breakfast during which time medication was being given, that individual health, personal and social care needs are being met. The home has appropriate policies and procedures to manage the storage, recording and distribution of medication. A random selection of residents’ medication was inspected and found to be satisfactory. The inspector witnessed care being given and was assured that residents are treated with respect and that their privacy is being respected. Information is now being gathered to inform the home of the wishes of residents following their death. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13, 14 The home provides an appropriate level of input into residents’ social, cultural, religious and recreational interests. EVIDENCE: Residents of the home are in the main very dependant on basic care and are not able to take full advantage of many of the social, cultural and recreational activities provided by their sister home. Residents are encouraged to maintain contact with relatives and friends from their past where appropriate. Residents are given choices and encouraged to maintain as much control over their lives as they are willing or able. On the day of the inspection the menu did not match the food being provided. The inspector was informed that the range and choice presented on the menu was not available. The inspector was informed that if a resident requested something different, then it would be provided. The registered person must ensure that the day’s recorded menu reflects the actual meal provided on the day and is amended to reflect any changes. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16, 17, 18 The home has policies and procedures to enable residents or their representatives to make a complaint. EVIDENCE: The size and management structure of the home ensures that concerns and complaints are dealt with. The home has a formal complaints procedure. No complaints have been logged for some time. Residents spoken to stated that, if they had a complaint, they would go to the proprietor or manager and felt confident that it would be resolved. Evidence was found through reading case files and speaking to residents that their legal rights are being protected and that they are protected from abuse. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26. The home is fit for purpose, well maintained and provides a safe environment for its residents. EVIDENCE: The home is fit for purpose and is maintained in a satisfactory manner. Communal facilities are available, both inside and out. The home has sufficient washing and bathing facilities. Where specialist equipment is required, an assessment is undertaken by an external specialist trained to do so. Staff training then takes place to enable carers to use this equipment in a safe manner. Residents all have single rooms. Many rooms do not have carpets and some rooms have metal-framed beds which, in the inspector’s opinion, gives the room a very medical feel. Evidence was found that residents are able to bring their own small possessions with them. On the day of the inspection the dining room smelt very strongly of urine. The rest of the home was clean and fresh smelling. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30. The home must tighten up on its recruitment procedures. EVIDENCE: On arrival at 7.50am the inspector took the opportunity to go into the dining room. Twelve residents were sat at the dining tables waiting for breakfast - no staff members were present. There was a strong smell of urine. The inspector drew the conclusion that the residents had been sat there for some time and that no one had checked where the smell was coming from. The inspector checked the dining room again at 8.05am and still the residents were without a staff member. The dining room continued to smell of urine throughout the time breakfast was taken. By about 8.10am staff were available in sufficient numbers to attend to the residents in the dining room. Evidence was found at inspection that staff are trained and experienced to complete the tasks required of them. On the day of the inspection two carers were being trained. This was being done in an appropriate way, taking into account the needs and dignity of the residents. The inspector read all staff files, case tracking, past experiences, references and police checks. Documentation found in the files varied in the quality and type of information required. Documentation could still be found in non-English formats and many references were addressed, “To whom it may concern”. The registered manager must ensure that all references are for the job advertised and that the reference is addressed to the proprietor or manager. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 15 Evidence was found that appropriate police checks had been sought. Where special home office status was required, this could be found on file. All staff are being trained and training profiles are available for future training. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37, 38. The home is professionally managed. EVIDENCE: The registered manager is experienced and trained to manage the care provision offered by the home. The registered manager is supported to do this by a staff group in sufficient numbers and experience in the care of the elderly. There is much evidence of the proprietor’s involvement in the home to support the manager. The home has sufficient policies and procedures to assist in the protection of potentially vulnerable adults. The home is managed in a professional manner and the inspector was informed that it was financially sound. Accounts are available for inspection if required. Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 18 YES 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 15 Regulation 17 Requirement The days menu must reflect the actual meal being taken. Changes must be reflected on the days menu. Documentation required for the safe recruitment of staff must be specific to the job and home. References should not be accepted if addressed To whom it may concern. Staff must be available in sufficient numbers to meet the needs of resident prior to and following mealtimes. The home must ensure that odour is effectively managed. Timescale for action 01/09/05 2. 26 19 01/09/05 3. 27 19 01/09/05 4. 26 23 01/09/05 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 24 Good Practice Recommendations The home should review all bedrooms where lino is not agreed as a part of the care plan. Where beds are to be replaced, consideration should be given to the use of domestic style bedding. H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 19 Mon Choisy Commission for Social Care Inspection Burgner House, Cascade Way Oxford Business Park South Cowley, Oxford OX4 2SU 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 Mon Choisy H57-H08 S13112 Mon Choisy V243444 090805 Stage 4.doc Version 1.40 Page 20 - 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!