Inspection on 04/03/08 for Mont Calm (Sandgate Road)

This inspection was carried out on 4th March 2008.

CSCI found this care home to be providing an Good 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 (Sandgate Road) 06/03/07

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mont Calm (Sandgate Road) 211 Sandgate Road Folkestone Kent CT20 2HU Lead Inspector Christine Lawrence Unannounced Inspection 4 March 2008 09:30 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 (Sandgate Road) DS0000068207.V359600.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 (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mont Calm (Sandgate Road) Address 211 Sandgate Road Folkestone Kent CT20 2HU 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) 01303 251093 Mr Stephen Anthony Castellani Mrs Dawn Gregory Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6th March 2007 Brief Description of the Service: Mont Calm (Sandgate Road) is a large, period, detached, corner property with high ceilings and character features. It is situated on the main road between Folkestone and Sandgate. Folkestone town centre and The Leas area are only a short distance away. There is a bus stop and railway station nearby. The home is registered to provide care for 20 older people who have dementia. Prospective residents or their relatives can request a statement of purpose that gives information about the service the home provides. Currently the scale of fees is between £367.82 and £500 per week. Hairdressing, chiropody and toiletries are not included in the fees. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and started at 10.20 and finished at 16.40. The inspector looked at various records in the home and also used information sent to the Commission for Social Care Inspection (CSCI) by the manager through her completion of the Annual Quality Assurance Assessment (AQAA). Information from the previous inspection was also referred to. We (CSCI) spoke with several residents. A tour of parts of the building was undertaken and we observed medications being given out. Staff were observed interacting with residents and we spoke to staff on duty as well as the manager and the deputy. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. What the service does well: What has improved since the last inspection? There were no requirements from the previous inspection. In the AQAA the manager, Dawn Gregory noted the following improvements:- making the garden secure; some bedrooms have been decorated and there have been new carpets laid and new bedroom furniture bought; new dining room tables and chairs; a new kitchenette area has been provided; a new washing machine and tumble dryer have been purchased; and continuing to look at menus and activities provided to ensure they reflect residents’ wishes. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 is not applicable to this home People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the home judges that it can meet their needs because it assesses their needs before they move in. EVIDENCE: The individual records of four residents were looked at during this inspection. They showed that assessments are carried out on the needs of prospective residents. The assessment is recorded and covers the topics noted in Standard 3 of the National Minimum Standards. The pre-admission assessment is used to compile an individual plan for each resident. The manager said that she only admits someone to Mont Calm (Sandgate Road) if she is sure that the home can meet their needs, both in the short term and the long term. The assessments are carried out by the manager and/or the deputy manager. Subsequent to any pre-admission visit the manager and deputy manager Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 9 always discuss whether the home can meet the needs of that individual. The assessments are used to compile care plans. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from having an individual plan of care which identifies how their health and care needs are to be met. They are protected by the home’s procedures for dealing with medication and they can be confident that they will be treated with respect. EVIDENCE: Each resident has an individual plan of care. There is sufficient detail in the plans to ensure that health and care needs are identified. Residents who completed surveys said they always received the medical support they needed. Staff spoken to said that there was enough information and detail in the plans to make sure that they can help and support the residents appropriately. Staff also said that the residents likes and dislikes in relation to their daily routines and preferences are known and responded to. The plans seen were up to date and any changes to residents’ needs were noted. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 11 Medication is appropriately stored and administered. The inspector observed medications being given out and looked at the medication administration records. Residents will be assessed to see if it would be appropriate for them to manage their own medication and one example of this was noted from care plans seen. Staff have received training regarding medication. Observations made during this inspection reflected that residents are treated with respect and their dignity is maintained. The care plans seen emphasized the importance of encouraging residents to be as independent as possible. How residents prefer to be addressed is noted within their individual records. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their preferences will be responded to and that they will be enabled to maintain contact with friends and family. Residents will be encouraged to make choices and they will benefit from healthy, wellpresented food at a time and place to suit them. EVIDENCE: There are various activities which take place within the home and the manager continues to ask residents what they would like. There is an in-house religious service every month which many of the residents attend. One new resident is Roman Catholic and the home is in the process of arranging for someone to visit. In their survey responses residents were positive about the activities provided and one person said there were activities but they preferred to spend time in their room and this was respected. There are lots of photographs on display showing different occasions which have been celebrated and one resident said that she really enjoyed all the parties and the staff dressing up and having fun. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 13 There are no restrictions on visitors and the manager said that family and friends are always invited to the celebrations and parties and are always made welcome when they visit. The menu seen was varied and the manager said that this is another area where they are continuing to ask people about what they would like. Residents expressed satisfaction with the food both in the surveys and through comments made during the inspection. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints would be handled objectively and in keeping with the home’s appropriate procedures and residents/their representatives can be confident that any concerns will be listened to, taken seriously and responded to. Staff are aware of adult protection issues and there are systems in place which create an atmosphere for protecting residents from abuse. EVIDENCE: The manager informed us that there have been no complaints since the last inspection. There is a complaints procedure and this is included in the statement of purpose which is given to all relatives or representatives when a new resident is admitted. Staff have received adult protection awareness training. Staff spoken to confirmed that they are aware of their responsibilities to keep residents safe and protected. There are appropriate policies and procedures in place, including disclosure of abuse and bad practice (whistle blowing), which are up to date. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 15 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 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a safe, well-maintained home which is homely, clean, comfortable, pleasant and hygienic. EVIDENCE: We carried out a tour of the communal areas and some of the residents’ bedrooms. A great deal of decoration and refurbishment has taken place and more is planned within a schedule of work planned. The home is comfortable and pleasant and the décor and furnishings are domestic in style. The garden area is safe and accessible to residents. The manager showed environmental risk assessments which have been completed for communal areas and residents’ rooms. The laundry room and routines for cleaning the house mean that it is maintained in a fresh and hygienic way. Residents who completed surveys Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 16 ticked ‘Always’ in response to the question ‘Is the home fresh and clean?’ and this was confirmed during the inspection. There are policies in place relating to infection control and thirteen members of staff have received infection control training. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by sufficient staff who are competent and trained. Residents are supported and protected by the home’s recruitment procedures. EVIDENCE: The manager uses a rota to ensure that there are sufficient staff on duty at all times and this is on display. The staff team consists of people of different ages and background and experience. Each day there is a manager or deputy and three care staff as well as a cook and a domestic. There are two staff on waking duty through the night. Seven staff have achieved their national vocational qualification at level 2 or above. The training records show that a programme of training is in place, including induction training. Staff confirmed, through completed surveys and through responses at the inspection, that they are provided with appropriate training. Two staff records were seen and they indicate that the home operates an appropriate recruitment procedure which includes seeking two references, using an application form to identify any gaps in employment history, undertaking criminal record bureau checks. The manager informed us that when appointed all staff are issued with an employee handbook and written terms and conditions of employment. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 18 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, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from the home being managed by someone who is competent, experienced and knowledgeable. Residents’ financial interests are safeguarded and their views are sought. Staff and residents have their health and safety promoted and protected. EVIDENCE: The manager has 10 years experience in working in care and she has achieved her national vocational qualification in care at level 4. She has also completed the registered manager’s award. She takes opportunities to keep up to date with mandatory training. Unfortunately the home does not have access to the internet but she stated that she tries to keep up to date with current practice. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 19 The lines of accountability within and external to the home are clear. There is a deputy manager. There are questionnaires which are sent out to relatives but the manager is planning to send these out more frequently. She has sent out one set since becoming manager but would like to do this twice a year. We discussed what she would do with the comments received and she is considering the best way to use this information. Policies and procedures are reviewed and updated. The homes involvement with residents’ finances is limited to managing some personal allowances. This is through relatives who have power of attorney or through social service departments. The manager demonstrated the procedures which were satisfactory. She sends a regular statement to whoever is responsible for the residents’ finances. A spot-check on maintenance and service contracts (gas safety, electrical installation and fire safety equipment) showed that they were appropriate and up to date with the exception of the electrical installation certificate. The manager checked with the maintenance person who confirmed that it was up to date but the paperwork must have been misplaced when the home changed hands. The manager has arranged for a new test to be undertaken. Training courses and instruction relating to aspects of health and safety are undertaken within a rolling programme and at the time of induction training. There is a range of policies and procedures relating to health and safety. Fire safety checks are carried out and accidents and other incidents are recorded and reported either under RIDDOR or Regulation 37 of The Care Homes Regulations. Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Mont Calm (Sandgate Road) DS0000068207.V359600.R01.S.doc Version 5.2 Page 23 - 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!