Inspection on 14/08/08 for Mont Calm Residential Home

This inspection was carried out on 14th August 2008.

CSCI found this care home to be providing an Adequate service.

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

Mont Calm Residential Home 14/08/07

Mont Calm Residential Home 14/12/06

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Mont Calm Residential Home 72-74 Bower Mount Road Maidstone Kent ME16 8AT Lead Inspector Robert Pettiford Unannounced Inspection 14th August 2008 07:25 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 Mont Calm Residential Home DS0000067183.V369258.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. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mont Calm Residential Home Address 72-74 Bower Mount Road Maidstone Kent ME16 8AT 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) 01622 752117 sam.reeves@montcalm.org.uk MGL Healthcare Ltd Mrs Marie Lisette Lisis Care Home 39 Category(ies) of Dementia - over 65 years of age (39) registration, with number of places Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Shared rooms are used for married couples, siblings or those whose professional assessments determines it meets their needs. The home is restricted to care for one service user who is under 65 years of age whose date of birth is 06/03/1948. 14th August 2007 Date of last inspection Brief Description of the Service: Mont Calm Residential Home is registered to provide personal care and accommodation for 39 older people with Dementia. The home is owned by MGL Healthcare Ltd. A family run business by Mr John Lisis, Mr Michael Lisis and Mrs Lisette Lisis. Having one other home nearby in Maidstone and another in Canterbury. The home consists of three properties directly next door to each other, (70,72 & 74 Bower Mount Road). Mont Calm has twenty-four single rooms, twelve of which have en-suite facilities and seven double bedrooms, three of which have en-suite facilities. There are shaft lifts in the houses and a staff call system. There is a large rear garden and ample parking to the front of the building. The home’s current fees range from £400.21 to £468 per week. This information was gained from the previous inspection. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is michaellisis@blueyonder.co.uk Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection took place at 7:25AM on 14th August 2008. The Inspector agreed and explained the inspection process with the Manager. The focus of the inspection was to assess Mont Calm in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The Inspector used a varied method of gathering evidence to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider/manager was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home has completed an annual quality assurance assessment questionnaire (AQAA), which was received on time. This provided the Inspector with information relating to What the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the CSCI to be able to make an informed decision about outcome areas. Further information can be found on the CSCI website with regards to information on KLORA’s and AQAA’s. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other area’s viewed included risk assessments, pre-admission assessments, rota’s, training records and recruitment records. In addition an environmental tour took place. The Inspector identified several residents for case tracking. In addition the inspector had the opportunity to speak with several of the residents and a number of staff. Additional evidence was gained to inform judgements following the observation of many of the residents and their interactions with staff. The Inspectors had the benefit of having the assistance of an expert by experience. The Commission is committed to involving experts by experience in both service and regulatory inspections. The Commission uses the term Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 6 ‘experts by experience’ to describe people who use services of have experiences of services. The report provided by the expert by experience has contributed towards helping the Inspectors making judgements about the home. What the service does well: What has improved since the last inspection? It was evident through the inspection process that the manager is taking appropriate steps to review and improves the standards of care within the home. However additional shortfalls were noted during this inspection. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident can be confident that their needs will be assessed prior to moving in to the home and they have the opportunity for visits prior to committing to living at the home. Intermediate care is not provided EVIDENCE: Records held showed that residents have an assessment, which identifies their individual needs prior to or on admission to the home. The residents, their families and health provide the information / social care professionals. This is then reflected into the care plans and these are developed in agreement with the individual where possible. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the needs of the individual. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 10 Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. The manager was requested to review the admissions form to ensure it included all of the elements as per the standards. No statutory requirement has been made at this time. The assessment process recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. The inspector recommended that the home reviews it equalities and diversity policy and considers carrying out an equalities impact assessment. This is requested to ensure that all of the information and policies relating to residents are inclusive to all members of the community and comply with all current legislation and good practice. Additionally it was recommended that Equality and Diversity training for all staff including management is considered and actioned. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s benefit from detailed care plans and are supported by staff that treat them with dignity and respect overall. There health care needs are generally met however they are not always sufficiently documented and supported with proactive healthcare. The home’s policy and procedures with regard to the handling and administration of medication needs to be reviewed to ensure that the recording of such medication meets with current guidance. Resident’s dignity is not always upheld all the time due to staffing convenience-dictating routines. EVIDENCE: Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 12 The inspector viewed and discussed with the manager the care records relating to several residents at Mont Calm. In the care plans viewed there were guidelines in respect to support needed. The home undertakes regular reviews. Formal reviews involving significant professionals and relatives where possible are also undertaken. Risk assessments are in place. However the inspector was of the opinion that they should be more detailed to evidence good practice, choice and independence. Evidence was not available that residents were involved in drawing up personal care plans where this is possible in the documentation and that they are consulted in reviewing and amending such care plans. The care planning system overall was of a good standard. The manager has introduced a more centred planning approach to care plans, which will have a socially lead model as its base. It was felt that further improvements could be made with regard to social care planning and fully exploring the resident’s needs and wishes where possible and opportunities for social development. The care plan is used as a working tool and is understood by all staff. It is written in clear language and can be used in an emergency by people who are not familiar with its content. The inspector viewed a sample of care records and specific health care records relating to several residents. Records viewed confirmed resident’s had access to a range of health care inputs as and when required and as part of regular health checks for some of the residents, but this was not the case for all residents care plans viewed. Whilst it was accepted that many of the relatives of resident’s might ensure that they have access to Dentists and Opticians etc it was not fully evidenced in the care plans. The home needs to ensure that resident’s have access to their chosen Doctor for medication reviews and health check up’s (if possible), Dentist, Optician in addition to identified specialist health care input. The manager is requested to that there is a provision to ensure that the home complies with standard 8.1 and regulation 12(1)(a) of the Care Home Regulations 2001. No requirement has been made at this time. Daily records were not wholly comprentaneous in that they did not follow current guidance. It was strongly recommended that the home follow the Nursing and Midwifery Council guidance “guidelines for records and record keeping”. The home benefits from two medication rooms. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication. MAR sheets were seen to be completed correctly and medication was stored appropriately. The manager confirmed that all staff that dispense medication have received appropriate training. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 13 PRN or as required medication protocols were written up, but did not contain sufficient detail. The PRN strategies need to fully inform staff when and how much and under what circumstances it should be given. The home could not demonstrate that as required medication is given following a comprehensive agreed protocol. Only one of the medication rooms had a signature sheet that identified the initials of each member of staff. It was recommended that a copy of the medication policy and current guidelines from the Royal Pharmaceutical Society of Great Britain be kept in each medication room. No requirement has been made at this time. It is evident through talking to members of staff at Mont Calm that the emotional health of the resident’s is of a high priority to the home and that staff are pro-active in maintaining and supporting resident’s with their emotional needs in order to maintain their quality of life from interactions witnessed. However when the inspector visited the home at 7:25AM out of a total number of residents being 38 it was found that 27 were up sitting in the lounge areas. Whilst it is accepted that many residents may choose to rise early it was felt by the inspector that having over 70 of the residents up at 7:25AM was a concern. The manager was requested to review the staffing arrangement to ensure that staffing convenience is not dictating routines. Care plans need to confirm that rising early is a choice. Information received prior to the inspection raised this as an issue. Future inspections will focus on this area. No statutory requirement has been made at this time. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Current residents enjoy a good lifestyle, which meets with their expectations. Relatives are actively encouraged to maintain contact with their relatives. The resident’s benefit on the whole from appetising meals and balanced diet offered at the home. However opportunities to improve choice and menu planning are possible. EVIDENCE: The majority of the residents spoken with confirmed they were happy with the lifestyle at Mont Calm and found the level of activities about right. The home benefits from two activities co-ordinators who work 20 hours each per week Staff normally arrange activities in the afternoon records are kept of what the activity is. A wide range of the activities is organised. Residents and staff confirm that Christmas parties and birthdays celebrations are also celebrated. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 15 The expert by experience witnessed dominoes and darts (safe version) being played, both of which were attended by approximately 6 people. Others joined in during the darts. All appeared to be having fun. Laughter was audible. I observed the activities co-ordinator at work. She had an excellent rapport with the people. She was appropriate with her language, caring and considerate to their needs. The expert by experience spoke with other people who chose not to join the activities, including some visiting relatives. They all felt that the activities were well received and they all had a choice to join in if they wished. They told the expert by experience about outings to places of interest, Bring and Buy Sale, a Garden Party, and other activities that go on in the home such as crafts, knitting, board games. The sales generate funding for the activities. The activities co-ordinator felt this funding was adequate for the task she carried out. One person spoke of one to one outings she has to town on a monthly basis with her good friend the activities co-ordinator, and I like to go out. This is a time of great pleasure. This person has been used to an active life and is missing physical activity. She would like more to do relating to exercise but said she understands this is difficult for one person only when there are so many as, I need a carer with me. The staff are able to carry out some activities during their duties when the activities co-ordinators are not at work. Staff spoke of setting up puzzles on the tables or taking people for walks in the garden, although with their other tasks they were not able to be as thorough in their input as the activities coordinators. The activity notice board is not used. The activities co-ordinator says she prefers to be flexible with the activities due to the varying needs of the people. She finds a timetable does not work. Another staff member agreed with this. Family and friends feel welcome and know they can visit the home at any time. Staff always make time to talk to visitors and share information with the agreement of the resident. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. Evidence was seen that residents can bring in personal items for their rooms and staff confirm this was encouraged. The residents spoken with said the food was of good quality and that they had a choice. Three full meals plus snacks were available every day with drinks readily available. Evidence was seen that the residents were offered a choice at every meal and that it was well balanced and nutritious. The inspector viewed the menus, which offered a selection of fruit and vegetables on a daily Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 16 basis. Specialist diets could be provided when advised by health care professionals or residents, including any cultural food needs. The general feeling amongst residents was that the food was good. However choice of fresh milk should be available along with butter to ensure that choice is further evidenced within the home. The expert by experience pointed out to the inspector that In the inspection report August 14th 2007 it was noted that the home intended to build up a portfolio of photographs of the meals to show the people who use the service and encourage them to make informed choices. The expert by experience spoke with the cook and the care staff and to date this has not been carried out. This is a good idea that needs to be considered to help dementia patients choose their meals. The expert by experience was at the home during lunch. It was witnessed that residents were going to the table some 30 minutes or more before the first course arrived at the table. However during this time staff were interacting with the people, drinks were provided and conversation was apparent. The meal began socially. The food provided that the expert by experience ate, was of good flavour. The texture of the potato pleasant and the custard made well. The expert by experience commented that the portion sizes were more than adequate in her opinion. Those in need of a soft diet were presented with a pureed meal in separate sections, meat, vegetables, and potato. The people were encouraged with their eating, some were supported by staff. It was a pleasure to see, not just care staff, but management and activities staff, and relatives, joining in the feeding as required. Three different people told the expert by experience that breakfast is served in the dining room at about 8 am (day shift begins at 7.45am). The expert by experience was told by a staff member that everyone living in the home, except one, attends the breakfast downstairs, and all are washed and dressed before this time. This would therefore suggest that getting up begins with the night staff before 7.45 am. The inspector commented on this earlier within the report. It was suggested by the expert by experience that breakfast is served on trays to the bedrooms. This would allow a slower waking up process and allow those who want to sleep longer time to do so. This would be seen as a good practice and the home is recommended that this be considered. The home is requested to seek further information from the Royal Institutes of Public Health Guide for Healthy Eating in Care Homes to provide more information. No requirement has been made at this time. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are aware of their rights with regard to making a complaint and to whom to complain. Residents are not wholly protected from the risk of abuse by the home’s Adult Protection policy and procedures. EVIDENCE: Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 18 A copy of the Home’s complaints procedures was seen and evidenced at the previous inspection and it was confirmed by the manager that it includes all the information outlined in the Standards. The inspector enquired if the service had changed or if there had been any amendments. The manager stated that no changes had been made. Residents spoken with felt confident that they are listened to and concerns are taken seriously. The complaints procedure referred to the Commission being part of Kent County Council. This is incorrect and should be amended. It was evidenced at the last inspection that the home is not meeting the standard with regard to the protection of residents. No further evidence suggests otherwise during this inspection. The home’s Policy for the Protection of Residents and staff “Whistle blowing” procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. The majority of staff have not been provided with training in abuse on evidence collected during the inspection. The training records show that fourteen out of thirty three staff have not received such training. The manager was requested to ensure as a priority that all staff have received training within the timescale stipulated. Failure to comply with the statutory within this report could result in enforcement action. Evidence was provided that staff have been checked with the Criminal Records bureau. The manager confirmed that all staff have been through the required recruitment checks prior to appointment, which includes checking the POVA (Protection of Vulnerable Adults) register. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in a well maintained environment which provides a homely warm atmosphere with safe access to comfortable indoor and outdoor communal areas Residents can feel confident that the home is kept clean and that policies and practices ensure that hygiene is maintained. EVIDENCE: The inspector observed that the home is set in well-maintained gardens. It was apparent that the individual and collective needs are being met in a comfortable environment. The standard of internal decoration and fixtures and fittings are well maintained and of a good quality. The home benefits from a Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 20 wide selection of communal area’s thus affording resident’s space should they so wish desire. The home was found to be clean. The area between the buildings however is open to the British weather. It is recommended that this area be covered appropriately to avoid the elements between the houses. In the view of the inspector ancillary staff are employed in sufficient numbers to ensure that standards relating to food hygiene are fully met. During the inspection it was noted that the home does have a washing machine with a sluice facility to ensure that hygiene standards are met to meet the needs of residents. The expert by experience noted that one of the communal bathrooms door did not close or lock. The home is requested to address this as a priority to afford dignity. The expert by experience commented that shared rooms were seen to have curtains that divided the room to allow for privacy. Two relatives told her that their mothers were happy with the double room arrangement, and had no complaints at all. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Whilst resident’s’ care, social and emotional needs are promoted by caring staff they are not trained to the required level to ensure residents safety and welfare. Residents are protected by the recruitment procedures within the home. EVIDENCE: The ratios of care staff to resident’s is determined according to the assessed needs of residents. Following discussions with staff, resident’s reviewing the rota and observations sufficient staff were on duty during day. However the home was requested to review its staffing arrangements in view of comments made by the inspector under standard 10. The home employs ancillary staff who work as cleaners, cooks, gardener/ maintenance staff. Thus allowing care staff the time to meet the needs of resident’s. From documentary evidence seen the standard of staff training was adequate overall with the majority of staff completing basic courses. However shortfalls Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 22 were noted with regard to 50 achieving a NVQ (National Vocational Qualification) Level 2 or above care qualification. Shortfalls were also noted with regard to staff training in abuse. This has been commented in more detail under standard 18.The manager confirmed that she would include within the home’s action plan that all staff have completed both adult protection and basic core training. The manager was requested to carry out a training needs analysis and was recommended to complete a up to date training matrix which would clearly identify levels of training for each member of staff. The manager confirmed that the home now has a development programme for all new staff, which meets Sector Skill’s council’s workforce training targets and ensures staff fulfill the aims of the home and meet the changing needs of resident’s. However evidence seen confirmed that this is not happening to specification within 6 weeks of appointment to their posts, and foundation training within 6 months. This was seen as a shortfall that is in need of being addressed as a priority. Of the four staff files sampled the home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The home’s recruitment files reviewed were seen to include all the information as required under schedule 2 of the Care Home Regulations 2001 on information given. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s benefit from an overall well run home with an experienced manager in post and is operated in their best interests overall and their views and opinions are important. However shortfalls were noted with regard to the lack of the Reg 26 provider visits and training. Standard 35, 38 not inspected. EVIDENCE: Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 24 The current Registered Manager who is also a Director of the provider company is intending to de-register and support the Deputy Manager to register. The Deputy Manager stated that she has the required qualifications and experience to register with the Commission as Registered Manager and will be applying to the Commission to be registered. Throughout the inspection the manager was open and honest and assisted in the inspection. The manager is aware of the issues raised and showed a commitment to work diligently to address them. Quality assurance was discussed and the views and opinions of many of the resident are sought. They confirmed a great deal of satisfaction in living within the home and felt confident that the staff and management valued their views and opinions. The manager confirmed that the home does undertake quality assurance by means of asking resident’s to complete questionnaires and seeks their views and opinions of relatives. However whilst the provider does visit the home regularly he does not complete what is known as a Regulation 26 visit in accordance with the Care Home Regulations 2001. This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. The inspector stated to the manager that the visits need to focus on outcomes for resident’s with regard to quality of care, staffing, adult protection, audits of policies and procedures and that they are followed, staff training, activities, health and safety etc. along with speaking to staff and resident’s. The provider intends to ensure that such visits now take place. The standard relating to health and safety has not been inspected on this occasion. Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 25 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x x x x Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP18 Regulation 13 (6) Requirement The registered person shall ensure that all staff has received Safeguarding Adult Protection Training to further protect residents from abuse. Outstanding from previous inspection 14th August 2007. Failure to comply within the designated timescale or without a further extension being agreed by the Commissions could result in formal legal enforcement action. 2. OP28 OP30 18(1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users— (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users; DS0000067183.V369258.R01.S.doc Timescale for action 30/09/08 14/02/09 Mont Calm Residential Home Version 5.2 Page 27 3 OP33 26(1) (c) ensure that the persons employed by the registered person to work at the care home receive— (i) training appropriate to the work they do. Regulation 26 visits do not currently occur. The provider needs to ensure that such visits audit the quality of care within the home include, staffing, adult protection, audits of policies and procedures and ensure that they are followed, staff training, activities, health and safety etc. along with speaking to staff and resident’s. 14/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mont Calm Residential Home DS0000067183.V369258.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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