Inspection on 17/09/08 for Mont Calm (Sturry)

This inspection was carried out on 17th September 2008.

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

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

Mont Calm (Sturry) 09/08/07

Mont Calm (Sturry) 11/08/06

Mont Calm (Sturry) 06/09/05

Mont Calm (Sturry) 23/05/05

Mont Calm (Sturry) 19/10/04

Mont Calm (Sturry) 13/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Mont Calm (Sturry) Star Lodge Park View Sturry Canterbury Kent CT2 0NW Lead Inspector Robert Pettiford Unannounced Inspection 17th and 25th September 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mont Calm (Sturry) DS0000035711.V365456.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 (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mont Calm (Sturry) Address Star Lodge Park View Sturry Canterbury Kent CT2 0NW 01227 710897 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) Stephen Anthony Castellani Mrs Susan Teresa Hancox Care Home 16 Category(ies) of Dementia - over 65 years of age (16) registration, with number of places Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2007 Brief Description of the Service: Mont Calm (Sturry) is a large modern detached house, which offers one shared bedroom and fourteen single bedrooms for residents. The home provides care and accommodation for up to 16 people who are 65 years of age or older and have dementia. There are local facilities nearby and access to public transport. There are parking places at the front of the building. There is a garden for residents use at the rear. Current fees range from £367 - £540 per week according to assessed personal need. Please contact the manager for further details Mont Calm (Sturry) DS0000035711.V365456.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 9:00AM on 17th and 25th September 2008. The Inspector agreed and explained the inspection process with the senior member of staff present on the 17th and the Registered Manager on the 25th. 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. A specialist pharmacy inspector who looked at the medication accompanied the inspector of the home. This enabled the Commission to make sound Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 6 judgements concerning the record management of medication within the home following concerns raised at the previous key inspection. What the service does well: What has improved since the last inspection? What they could do better: On standards inspected during this key announced inspection some shortfalls were noted and recommendations made with regard to: The home does not keep clear and detailed records around medicines use. Good detailed policies on medicines management are required. Fixtures and fittings and general decoration were seen to be of a poor to adequate standard. Urgent remedial work was seen as being needed due to the demands placed on the building and further decoration of rooms to make the home appear more homely. The home is generally clean and tidy. However some of the carpets were in need of cleaning and their suitability in certain area’s assessed due to odour problems. Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 7 The manager is working to meet the standards required but is hampered because the providers development plans as outlined in the previous report have not happened, the majority of these are environmental. The provider is urged to look seriously at addressing these issues without delay. Following this visit and the subsequent report, the Provider will be required to provide the Commission with a formal Improvement Plan. The inspection of the medication management within the home evidenced continued non-compliance with current guidance. This means that people are not having the right sort of support to take medication safely. We issued a code B Notice that outlined that an offence may have been committed through failure to keep true and accurate records around medicines use and storage. A representative of the registered provider of the home does visit the home and completes what is known as a Regulation 26 visit (Statutory documented visits by the provider to monitor standards within the home). However this does not fully monitor health and safety, maintenance to an acceptable level and ensure that requirements are met from previous reports. Such visits do focus on outcomes for residents with regard to quality of care, staffing, adult protection, staff training, Activities, along with speaking to staff. Failure to address the requirements within this report could result in formal enforcement action. 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 (Sturry) DS0000035711.V365456.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 (Sturry) DS0000035711.V365456.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. The personalised pre admission assessment means that resident’s diverse needs are identified and planned before they move into the home. Intermediate Care is not provided. EVIDENCE: The admissions process was fully inspected at the last key inspection and no evidence would suggest that the process has changed. The Manager visits prospective residents prior to admission to make a decision about whether the home can meet the person’s needs. Information is obtained from relevant health care professionals to assist in assessments. Residents and/or their Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 10 relatives are able to visit the home before moving in. The home’s registration category is for service users with dementia. The home does not offer the facility of intermediate care. Mont Calm (Sturry) DS0000035711.V365456.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 good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from detailed care plans overall and that their needs will be met. Residents cannot feel wholly confident that the way the home manages medication is safe and secure. Staff treat residents with respect and maintain their privacy and dignity. EVIDENCE: Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 12 The inspector viewed and discussed with the member of staff present at the inspection 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. Evidence was not seen in all plans of care viewed that residents were involved in drawing up personal care plans, where this is possible. The care planning system overall was of a good standard. We discussed improvements by having a more person centred planning approach to care plans. 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 and enrichment. 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. The documentation seen confirmed that all Residents have a Doctor and visits from other health professionals are arranged and enabled. Health professionals are documented. Risk assessments are in place with regard to identifying the risk and the control measures needed to minimise risks. During the inspection we saw that that residents were seen making choices about their lives and were seen to be part of the decision process. A relaxed atmosphere was noted with the residents interacting with staff. The inspector also had the opportunity to speak with several residents who expressed a great deal of satisfaction with the care offered and given. They felt that the home offered an inclusive family atmosphere and that the manager was receptive to their comments and suggestions. Daily records had spaces and gaps. We recommended that the home follow the Nursing and Midwifery Council guidance “guidelines for records and record keeping”. There was clear evidence available to demonstrate that the healthcare needs of service users are met. Records are maintained of all healthcare professional input including district nurses, GPs. The records include outcomes of any consultations, which are then included within plans of care and appropriately communicated to staff as part of regular health checks. The home ensures that residents have access to their chosen Doctor where possible for Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 13 medication reviews. Residents have regular access to health check up’s, Dentist, Optician and so on, but the system of planning and recording when these visits are needed, or have taken place could improve. The standard of daily record keeping could be improved. The amount of detail in entries is dependent on the staff member completing the record. There were incidences where a tick chart system introduced had not been completed properly and was not sufficient in detail to represent a daily record. The home was recommended to move away from tick boxes and consider better training for staff on what constitutes a daily record. When well written, daily records help the manager audit the care being provided to residents and evidence that staff are following the guidelines in the care plan. Detailed policies on medicines management were not available so that members of staff did not have clear guidance and could not follow a common approach when managing medicines. Medicines in use were stored safely however unauthorised members of staff could access the medicines awaiting disposal. The storage of the medicine key was not secure. The home does not have clear and detailed records around medicines use. For example: There were no records of medicine disposals; when a variable dose is prescribed the actual dose given is not recorded and there were 29 signatures for giving a medicine when only 28 doses had been received. There was no individual care plan describing how to give a medicine prescribed to be given only when required. A sample number of Care plans were checked. These had records of doctors visit and district nurse input. There was no guidelines on medicine prescribed on a when required basis. There are four pages on medicine management procedures, which do not cover all aspects of medicines management and will need a review. Service users privacy and dignity are respected. Staff knock on doors before entering and call service users by their preferred name. Interactions between staff and service users were observed as friendly and relaxed but respectful. Mont Calm (Sturry) DS0000035711.V365456.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. Service users social and cultural needs are supported and met; they are supported to maintain contact with family, friends and the wider community; they are given opportunities to exercise choice, which gives them a degree of control over their lives. They also receive a balanced, wholesome and appealing diet. EVIDENCE: Daily life and social activities was fully inspected at the last key inspection and no evidence would suggest that standards have not been maintained from observations at time of inspection. The home has an activities programme and arranges a variety of activities to suit residents’ abilities and choices. There are photos on bedroom doors; and photos and examples of service users work were displayed throughout the home. The manager stated previously that the individual’s permission had been gained to do this. There are no formal residents meetings as such but residents and relatives are encouraged to give their views. Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 15 Residents are helped to make choices about their daily lives. Several residents were seen chatting to each other and staff and exercising a degree of control over how they spend their day. Some residents like to help lay up the tables this was observed by the inspector. Some resident’s display challenging behaviour, this is well managed by distraction and behaviour management techniques to good effect. This was observed by the inspector at the time of inspection. The staff know residents likes and dislikes well and use their insight to manage potentially difficult situations. Food is seen as important in the home and they go to considerable lengths to ensure people have the right type of food and the assistance they need at meal times. They record the amount of food taken at each meal to ensure good dietary intake for individuals from evidence seen. Nutritional assessments are in place for residents and weight monitoring records. There is a sweet trolley with three choices at meal times. Appropriate assistance was observed being offered by staff to residents who needed help and support at mealtimes. Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives can be confident that their complaints and concerns will be listened to and acted upon. The home is aware of adult protection procedures and issues so they have the skill and ability to fully protect residents from the potential for abuse. EVIDENCE: The home has a clear complaints procedure. A copy is displayed in the hallway and included in the home’s information documents. Copies of complaints forms are available for staff to use as well if needed. The manager is effective in managing areas of dissatisfaction at an early stage and no one raised any major concerns before or during the inspection. However it requires to be amended to state that a complaint can be referred to The Commission for Social Care inspection and Social Services at any time of the complaint. Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 17 The inspector viewed and discussed copies of the Home’s Policy for the Protection of Residents and staff “Whistle blowing” procedure. 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. Evidence from the previous inspection showed most staff have attended safeguarding adults training and more is planned. This was also the case for this inspection. ‘Training for Care’ in partnership with Kent County Council and South Kent College provides the training. Staff spoken with had a good understanding of safeguarding adults’ issues. The home also had the Lead Agencies revised protocols for safeguarding adults available to them for guidance. Criminal Record Bureau Checks (CRB) have been obtained for all staff. Evidence was seen at time of inspection. The Registered Manager is aware of her obligations with regard to ensuring the safety of Residents and protecting them from abuse. It was recommended however that the home refers to the Criminal Records Bureau and renews CRB’s in accordance to its current guidance. Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 18 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): 19,20,21,22,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents cannot be confident that the home is well maintained and decorated to an acceptable standard. Residents cannot feel confident that high standards of infection control are being maintained. EVIDENCE: The Inspector undertook a tour of the home including viewing some service users rooms, bathroom/toilet facilities and communal areas. Fixtures and fittings and general decoration were seen to be of a poor to adequate standard. Urgent remedial work was seen as being needed due to the demands placed on the building and further decoration of rooms to make the home appear more homely. The home is generally clean and tidy. However some of the carpets were in need of cleaning and their suitability in certain area’s Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 19 assessed due to odour problems. Whilst following discussions with staff they confirmed that they try to keep the home clean, which staff commented was a difficult task. A side room to the kitchen had a floor that was in need of replacement. It was evident that a previous piece of furniture had been removed which left the floor partly uncovered and showed concrete, which thorough cleaning is not possible. We have now been told that this is being sorted out. The previous report highlighted the need to provide facilities for residents who smoke. The manager stated that no residents currently smoked within the home and that the statement of purpose has been amended to state that it is was a non-smoking home. The service does not have a rolling programme to improve the decoration, fixtures and fittings. At time of inspection major building works were planned to build an extension to provide additional bedrooms and extend the kitchen .It is hoped that once all works are approved and completed that this will result in an improvement to the whole home. The proposed extension will include a complete refurbishment of the main kitchen to conform to current legislation and provide improved access to the garden area. Plans also include the introduction to the home of a medication store, a sluice area, new laundry and a shaft lift. The home has a very aged chair lift, which gives access to the first floor to residents unable to negotiate stairs. The home does not have a passenger lift. The manager stated at the last inspection that some residents find using the chair lift difficult without help and support. Exiting from the chair lift at the top of the stairs for instance can be difficult to negotiate; it involves the individual stepping across the top stairs to reach the flat landing area. The difficulty with regard to the chair lift was highlighted in the last key inspection on the 9th August 2007. It is hoped once the extension is built and the shaft lift installed this will solve the problem. In the meantime the manager stated all residents have individual risk assessments for the chair lift and it is serviced regularly. The senior care confirmed that the accident record indicated that no accidents had occurred around the chair lift in the last 18 months and he was not aware of any chair lift related accidents in the six years he had worked at the home. Currently access to the rear garden is not wheelchair friendly and would involve residents going through the home’s main kitchen, which is not acceptable. They are alternatively able to exit from the dining room through a door in the corner. However, this involves the resident going down a set of three concrete steps, which again is not ideal. The front car park surface is also uneven and presents a similar hazard to people accessing the front of the building. Window frames and external fascias have pealing paint and are in need of refurbishment. The manager stated that the access to the garden would be improved once the extension is built. Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 20 The downstairs communal bathroom houses a bath hoist and a Jacuzzi style bath. The water outlets on the Jacuzzi were stained dark brown and scaled. The manager stated that the bath is not regularly serviced. The manager told us that in view of the difficulties with keeping this bath hygienic, it would be replaced as soon as possible. Rusty commodes were seen in some of the bedrooms, which did not contribute to good cleanliness and infection control management. The manager stated that these would be replaced. The home currently has no sluice for staff use and commode pots are emptied into a toilet and washed in a sink not used by residents. It will be a requirement that the Health Protection Unit at Preston Hall are contacted by the manager and asked to provide them with infection control guidance. This is an outstanding issue from the last inspection. The manager stated that this would be fully addressed once the extension is approved and built in the meantime advice would be sought. Service users bedrooms are personalised to meet their individual needs. They are encouraged to bring in some of their own belongings to make the rooms more homely and to aid orientation. The manager stated that lockable storage facilities are not provided for individual residents in their bedrooms. Providing this facility was a requirement at the last inspection, and must now be met so that people have a place to store treasured possessions if they want to. We were pleased to see that risk assessments for individuals around having a bedroom key were in place. Radiators are now covered within the home, meeting a requirement from the previous report. The home will be required to provide the Commission with an improvement plan within timescales to address the statutory requirements in this report. Failure to improve the requirements within this report could result in formal legal enforcement action. Mont Calm (Sturry) DS0000035711.V365456.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 good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a dedicated staff team who are well supported. The home continues to train and develop its staff to ensure residents’ needs are met at all times. EVIDENCE: The manager continues to use the residential forum staffing guidelines when assessing how many staff are needed on duty. There were sufficient staff on duty to meet the needs of residents on the day of the site visit. Currently the home has 90 of care staff trained to NVQ level 2 or above which is commendable. Since the last inspection the manager has reviewed all staff training records and statutory training for staff, which required updating. Training courses are needed to be booked to ensure staff are updated with current practice. Staff realise that it is a requirement for the home to evidence that staff individually and collectively have the skills and knowledge to meet the needs of residents accommodated. The senior carer present on the first day of Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 22 inspection was very positive about training and was very enthusiastic about obtaining further skills and training. People applying to work at the home have to complete an application form, provide two references and have a Criminal Records Bureau check and a POVA first check. Recruitment procedures are largely sound and protect residents from any potential for harm. The manager was requested to carry out an audit to gather as much of the missing information as possible. All staff receives induction training when they are first employed in the home. Induction has been upgraded to reflect the new Skills for Care common induction standards, further enhanced to include specific dementia training. The manager is in the process of developing induction even further. The home is aware that it must also provide foundation training for new staff. The staff training records indicated undertaken training. Individual and group staff training needs had been identified. From documentary evidence seen the standard of staff training was good, with the majority of staff completing basic and additional courses. However some gaps in training was evident. The manager stated that training within the home would be reviewed. No requirement has been made at this time. Mont Calm (Sturry) DS0000035711.V365456.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): 31,32,33,36,38 Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Although the home has a dedicated and generally effective manager the operation of the home does not fully safeguard residents with regard to standards of decoration, maintenance, infection control and medication. EVIDENCE: The registered manager has the required qualification and experience, is competent to run the home and meets its stated aims and objectives. Evidence supports that she puts the needs of the residents first and is very supportive of staff. We found that some areas could be improved, such as medication management and infection control issues by the direct action of the Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 24 manager. But we also note that much of the environmental shortfalls are outside of her direct control. Quality assurance was discussed and the views and opinions of many of the relatives and healthcare professionals are sought. Evidence of this was gained by the quality and quantity of comment cards received by CSCI. Official visits to the home on behalf of the responsible individual (the owner) are taking place. We found through that these reports are not being used to monitor standards within the home, so they do not ensure that requirements are met from previous reports. But we were pleased to find that these visits do focus on outcomes for residents with regard to quality of care, staffing, adult protection, staff training, activities along with speaking to staff. Prior evidence confirmed the home has sound procedures for looking after service users monies and funds left with them are securely stored. Expenditure is appropriately recorded, with receipts kept. Records seen are kept in a manner that preserve confidentiality. The manager said that all care staff receive formal supervision. This covers all aspects of their practice and training needs. They are also regularly observed in their work, and have annual appraisals, which is good practice. But we found that planning for supervisions was not consistent, and this meant that for some staff, supervision is not always happening six times a year. The manager has met the requirement to provide supervision, but for this to be really meaningful should improve planning. We discussed environmental improvements with the responsible individual (the owner). It is of concern that significant issues around providing a homely house that is decorated and maintained to an acceptable standard still remain outstanding. Whilst we appreciate that planning applications can take a long time, other areas of the home that will not be directly affected by the proposed extension could be improved. Failure to address the requirements within this report could result in formal enforcement action. Accident recording is detailed and up to date. The home’s fire logbook was also in order, with all tests up to date. Staff have had fire instruction and more training is currently being planned. The home has up to date fire risk assessments and they have addressed the Fire Officers requirements listed following the fire safety audit undertaken on 21st June 2007. Mont Calm (Sturry) DS0000035711.V365456.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 3 9 2 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 1 2 2 2 x x x 1 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 2 2 2 x x 2 x 2 Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Requirement Medicines must be stored securely with access for authorised members of staff only. This is to ensure the safety of people in the home. To make sure a common approach is followed when dealing with medicines which show that people get the correct medicines; Clear and comprehensive policies and procedures for the receipt, recording, storage, safe handling, administration and disposal of medicines, specific to the home, must be produced. 3 OP9 13(2) To make sure a common approach is followed when dealing with medicines which show that people get the correct medicines; Particular improvements are required around Accurate records of medicines given to people and of medicines returned to pharmacy for Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 27 Timescale for action 20/12/08 2 OP9 13(2) 20/12/08 20/12/08 4 OP19 23(2)(o) 5 OP19 13 (4) (a) 6 OP24 12(4)(a) 23(2)(m) 7 OP26 12(1), 13(3)(4) (c) 16(2)(j) disposal. Suitable access to the rear garden must be put in place so that residents use this facility. This is a previously unmet requirement. The provider must take such steps to ensure that the environment is well maintained and free from health and safety hazards, for example, the kitchen floor; access to the garden and car-park and replacement of old and worn carpets. This is a previously unmet requirement. So that residents have a choice to use lockable facilities to store their personal possessions, a lockable space must be provided in individual bedrooms. This is a previously unmet requirement. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, In that: The manager must seek advice from the The Kent Health Protection Unit. Any work found to be necessary must be included in the home’s Improvement Plan and details of actions to be taken/proposed with completion dates included. 01/01/09 01/12/08 01/12/08 20/11/08 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 Good Practice Recommendations DS0000035711.V365456.R01.S.doc Version 5.2 Page 28 Mont Calm (Sturry) Standard 1 OP33 The registered person further develops the quality assurance systems. Results should be shared with stakeholders. To have clear, individual guidelines on the criteria of when to give a medicine prescribed on a ‘when required’ basis. 2 OP9 Mont Calm (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 29 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 (Sturry) DS0000035711.V365456.R01.S.doc Version 5.2 Page 30 - 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. 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