Inspection on 09/08/07 for Mont Calm (Sturry)

This inspection was carried out on 9th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Mont Calm (Sturry) 17/09/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mont Calm (Sturry) Star Lodge Park View Sturry Canterbury Kent CT2 0NW Lead Inspector Marion Weller Key Unannounced Inspection 10:00 9th August 2007 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.V345899.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.V345899.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.V345899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 2006 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 - £520 per week according to assessed personal need. Please contact the manager for further details Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Marion Weller, Regulatory Inspector, who was in Mont Calm (Sturry) on Thursday 9th August 2007 from 10.00 a.m. until 4:30 pm. During that time the Inspector spoke with the manager, some of the residents, some staff and visitors to the home. Some judgements about the quality of life within the home were taken from observations and conversation. Some records and documents were looked at. In addition, parts of the building and grounds were toured. Due to the service type it is not possible to accurately incorporate residents views into this report however, statements made during the visit included: “I am thoroughly spoilt here” “Extremely happy with the care and attention my relative receives – it gives us complete peace of mind when we leave here.” And “They could not do better!” “Not as good as it used to be” The Manager and staff gave their full co-operation throughout the inspection. What the service does well: Mont Calm (Sturry) is friendly, welcoming and has a relaxed and inclusive atmosphere. Prospective residents benefit from a full assessment of their needs and they or their representatives are able to look around the home before they decide to move in. The home is effective in helping residents to settle in. Residents are treated with respect and there are arrangements in place to protect and maintain their privacy and dignity. Relatives and friends felt they were always made welcome in the home and that important information was passed on to them. The home enjoys good relationships with other health and social care professionals. The Registered Manager runs the home efficiently and is passionate in her approach to the care of older people with dementia. 90 of care staff are trained to NVQ Level 2 or above. Which is commendable. Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 6 Meals at the home are innovative, nutritious, well balanced and attractively served. The cleanliness in the home is generally good. What has improved since the last inspection? The frayed carpet in the residents lounge has been replaced. This has improved the home’s environment and eliminated a significant trip hazard for residents. Some work has now been completed in the garden. A gardener was employed to relay the patio. On the last visit the patio was seen to be very uneven and presented a trip hazard for people accessing the area. To date four radiator covers have been fitted in areas accessed by residents. More work is planned. Improvements to the home’s kitchen highlighted in the Environmental Health Officers report of 2004 have now been carried out. In addition to this a new extractor fan has been fitted. All staff have undergone food hygiene training and the cook has completed a course in providing food for the older person. Kitchen paperwork required to evidence good practice has been obtained following the cook’s attendance at the ‘Safer Food, Better Business Course’. Some parts of the manual still have to be implemented. The cook and manager said recording would commence shortly. Following a fire safety audit of the premises on 21st June 2007 the manager confirms that work specified by the Kent Fire Safety Inspector has now been actioned to secure residents, staff and visitors safety in the home. A follow up inspection will be undertaken to ensure the home’s full compliance with the breaches in fire safety legislation noted. Two new boilers have been installed. The manager has reviewed all staff training records and statutory training for staff, which required updating. Some training courses have been attended and more are booked. Health and Safety certificates are now available in the home for inspection purposes. The manager has reviewed all residents’ contracts. These now meet with Regulation however; some still require to be signed. Mont Calm (Sturry) DS0000035711.V345899.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 (Sturry) DS0000035711.V345899.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.V345899.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): 123456 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People accessing and using this service largely have all the information they need to make an informed decision about whether the service is right for them. The personalised pre admission assessment means that residents’ diverse needs are identified and planned before they move into the home and they are given a contract that clearly tells them about the service they will receive. EVIDENCE: The home’s statement of purpose and service user guide is easy to read, informative and detailed however it contains some out of date information and requires revision to ensure it remains current and content fully meets the demands of Regulation. Both documents should be clearly dated for inspection purposes to evidence good practice. Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 10 In addition to the information documents mentioned the manager has produced a ‘Welcome to Mont Calm’ booklet for Residents and/or their relatives further information. Each resident is given a contract on moving in which clearly states the rights and responsibilities of both parties. The manager has reviewed all residents’ contracts since the Commissions last visit. These now meet with the demands of Regulation however; some still require to be signed. A good practice recommendation will be made regarding this issue. 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 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.V345899.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. Residents’ health and social care needs are set out in an individual plan of care. Improved care planning would better promote residents’ health and welfare. Improvements in daily record entries would help the manager audit the care provided and evidence staff are following the guidelines in care plans. More consistent adherence to the procedures for the administration of medicines would better protect residents. Staff treat residents with respect and maintain their privacy and dignity. EVIDENCE: Each resident has a care plan. Three were examined in detail. All had been completed consistently and adequately addressed individual needs and potential risks. However, it was noted that the care plan format does not fully lend itself to providing detailed actions and guidance for staff to follow. On occasions the terminology used was overly complex and could lead to Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 12 confusion and a lack of understanding of what is required to meet residents needs. It is important that care plans provide easily accessible information to identify individuals’ care needs and be directive to ensure staff know how the needs are to be met. Care plans seen emphasised individual abilities and therefore encouraged independence however, there remains scope for further development in the area of sound person centred planning that is of particular benefit to this client group. Plans were seen to be reviewed on a monthly basis in most cases, although the home could tighten up in this regard. 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 and complimentary healthcare professionals such as Chiropodists, Opticians and Dentists. The records include outcomes of any consultations, which are then included within plans of care and appropriately communicated to staff. Nutritional assessments are completed and weight charts are routinely maintained. Other healthcare needs such as pressure area care; continence issues and oral health are documented within care plans as necessary. The home only has domestic type ‘stand on’ scales. The manager stated that ‘sit in’ scales designed to meet all resident capacities are on order. 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 ‘all care given’ was recorded. This is not helpful or adequate. Daily records when well written help the manager audit the care being provided to residents and evidence that staff are following the guidelines in the care plan. It is in the home’s interests to be able to show what they have done for individuals and records well maintained provide evidence on which to base the individual’s monthly review and evidence that the home is following the assessment of needs. Medication administration processes and medication administration records were inspected. The home has access to a lockable medication trolley, which contains medication currently being administered. There is no dedicated storage area for medicines in the home. It is therefore difficult to maintain optimum storage temperatures for medicines kept. Medication newly delivered and items for return to the Pharmacy are stored in the manager’s office. Although the room is locked when not in use, this is not ideal. The manager said there are plans to include a medication store in the home’s proposed building extension. The manager stated that the only cold storage medication items stored are usually eye drops, prior to opening, and these are stored in a locked box inside the spare fridge in the staff room. A recommendation has Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 13 been strongly made that a dedicated, lockable, drugs fridge be purchased. This will be the second time this good practice recommendation has been made. Medication records contained hand written transcriptions that were not signed by the individual recording the details, neither were they signed by a second person to confirm accuracy of transcription. Some hand written transcriptions did not contain all the information included on the pharmacists label. Details of hand written medication dosages changed by order of the individuals GP had equally not been signed. The current list of medication signatories was not up to date and now requires revision. All staff that administers medication have had appropriate training. It is therefore important that the manager ensures medicines are stored and administered in accordance with current good practice guidelines for residential home’s. Staff should have their ongoing competency regularly tested, with records maintained as evidence. A requirement will be issued in the respect of medication administration in the home. 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.V345899.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: The home has an activities programme and arranges a variety of activities to suit residents’ abilities and choices. Activities included music and movement fortnightly, occasional make up sessions, song and dance, knitting circles, old time sing songs, seasonal parties, group coffee mornings, there is an in house hairdresser who visits weekly. A local hairdresser also accommodates residents in her shop in the community. There are photos on bedroom doors; and photos and examples of service users work were displayed throughout the home. The manager stated that the individual’s permission had been gained to do this. Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 15 Service users’ religious and cultural needs are supported; there is a monthly Holy Communion service. One lady is helped to enjoy a cigarette in the garden, she sits with staff and they chat – she told me she particularly enjoys this time alone with them. There are no formal residents meetings as such but residents and relatives are encouraged to give their views. Service users are helped to make choices about their daily lives. A couple of residents choose to go back to bed after tea, some rise later in the mornings. There are no set routines and people have a degree of control over how they spend their day. Some residents display very challenging behaviour, this is well managed by distraction and behaviour management techniques to good effect. The staff know residents likes and dislikes well and use their insight to manage potentially difficult situations. There were visitors in the home on the day of the site visit. They were treated in a very friendly and supportive manner and were given refreshments. The home does not charge for meals taken with residents and relatives are encouraged to stay and enjoy a meal when they visit. Some residents like to help lay up the tables and wash up – this is accommodated. Residents’ preferences and likes and dislikes are detailed in care plans. 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 have started to record the amount of food taken at each meal to ensure good dietary intake for individuals. Nutritional assessments are in place for residents and weight monitoring records. There is a sweet trolley with three choices at meal times. The Cook is aware of dealing with dysphasia and has guidance available. The Cook has completed the ‘better food better business’ training recently. The manual and records provided by the EHO to aid catering requirements in residential home’s was on site. Its use is being planned. Currently the home caters for diabetics and for allergies of shellfish, peanuts, cod, and lactose. Appropriate assistance was observed being offered by staff to residents who needed help and support at mealtimes. Mont Calm (Sturry) DS0000035711.V345899.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 continues to train staff to be 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. There have been no formal complaints since the last inspection. 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. The home currently does not record minor concerns and neither does it record compliments, of which the manager says there are a number. This practice is recommended. Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 17 Most staff have attended safeguarding adults training and more is planned. ‘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. Mont Calm (Sturry) DS0000035711.V345899.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 24 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although it is clear that some improvements have been made, the quality of life and safety of some residents continues to be adversely affected by the home’s poor environment. EVIDENCE: Mont Calm (Sturry) is a detached building with residents’ accommodation arranged over two floors. It was registered under previous legislation and consequently there is not the availability of space in some areas of the home that a new registration would require, for instance some bedrooms would not be registered under the Care Standards Act 2000. Changes in residential and social care mean that people referred to care home’s have increased frailties and care needs than previously. Whilst Mont Calm is able to offer a very “homely” environment, from observation, it could be very difficult for staff to meet residents’ care needs safely if for instance residents become immobile or Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 19 bedfast. For example, the small entrance hallway and stairs leading from it form the shape of a very restricted and sharp dogleg corner, which makes transporting immobile residents and equipment between floors almost impossible. A recent incident involving a resident who was unwell and needed to be admitted to hospital highlighted the difficulties the environment can cause. 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 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 environment of the home is disappointing. Some environmental problems still need to be addressed that adversely affect service users safety and welfare. Following the last inspection the home provided the Commission with an action plan to resolve some of the issues highlighted in the report. It is acknowledged that some improvements have been made, but more work still needs to be done. 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 patio area has been re-laid but the garden paths remain uneven and present a trip hazard. The front car park surface is also uneven and presents a similar hazard to people accessing the front of the building. The back garden has been cleared but there is a large pile of garden debris that has accumulated in one corner and arrangements have not been made for its removal. From some upstairs windows you can view items of the home’s old furniture and obsolete equipment, which have been left in exterior walkways and not removed from site. The items are not in resident access areas but look unsightly and give the home a very run down and shabby appearance. Window frames and external fascias have pealing paint and are in need of refurbishment. One resident enjoys a cigarette. There is not a smoking lounge in the home. Residents who wish to smoke go out to an uncovered patio area in the garden. The arrangements for smokers are not mentioned in the home’s service user’s guide. The home has two communal bathrooms for 16 residents. The first floor unassisted bathroom had been refurbished. 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 water outlet jets must be included in Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 20 weekly cleaning schedules and serious consideration given to a regular servicing and maintenance regime to eliminate any potential health and safety risk this presents to people using the communal facility. One communal toilet had exposed pipe work and areas where items had been removed from walls and not made good. This is unacceptable. Communal bathrooms had liquid soap and paper towels for people’s use. Some liquid soap dispensers were seen to be empty. Bars of hard soap were being used in some bathrooms and toilets. The use of such items may compromise the home’s infection control procedures. The home has no sluice for staff use and commode pots are emptied into toilets and washed in sinks. It will be a requirement that the Health Protection Unit at Preston Hall are contacted by the manager and asked to undertake a full audit of the home to provide them with infection control guidance and a subsequent written report of their findings. The report will be shared with the Commission. 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 residents in each of the home’s bedrooms as standards require, neither are residents provided with keys to their rooms on admission unless their risk assessment suggest otherwise. No risk assessments of this type were included in the care plans seen. There are few radiator covers fitted in service users bedrooms. As all service users suffer from dementia this could pose a health and safety risk. A requirement was previously made regarding this matter. The home’s current action plan states that radiators and pipe work presenting a significant risk to residents would be prioritised and covered at a rate of two a month commencing February 2007. This should have meant that by the site visit date of August 2007 fourteen being in position. The manager states that four have been covered to date. The owner of Mont Calm is proposing to extend the building and increase maximum occupancy to 20 people. The manager said that an architect is currently amending building plans. The proposed drawings for the 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 and a new laundry. The manager stated that work should be completed in 12 months. The home will be required to provide the Commission with an improvement plan with agreed timescales to address the statutory requirements in this and the previous report. Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 21 Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 22 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 and supervised. The home continues to effectively 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. Some training courses have been attended and more are booked. There was previous resistance from some staff to attending training and achieving the NVQ qualification however, this appears to have now been overcome. Staff realise that it is a requirement for the home to evidence that staff individually Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 23 and collectively have the skills and knowledge to meet the needs of residents accommodated. 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. 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 manager is very much in evidence in the home and it is clear that all staff are well supported by her presence and benefit from her leadership and guidance. Visitors spoken with on the day of the site visit spoke highly of the staff. Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 24 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 effective manager the operation of the home does not fully safeguard residents. EVIDENCE: The manager has completed the Registered Managers Award and NVQ 4 in care and has suitable experience to run the home. The manager’s approach creates a positive and inclusive atmosphere, and she communicates a clear sense of direction and leadership. It was obvious that residents and staff find her approachable, personable and supportive. She was commendably open and honest throughout the inspection. Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 25 The home has some quality assurance strategies in place. Questionnaires are sent to families, health and social care professionals and to other visitors. Results are not currently collated into a report and shared with other stakeholders, neither are the results shared with the commission. This needs to be addressed. The registered provider has not completed monthly Regulation 26 visits or prepared a report on the conduct of the home for some time. The last report seen by the inspector was dated 15/09/2006. 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. Appropriate insurance cover is provided for the home and a current insurance certificate is displayed. Records seen are kept in a manner that preserve confidentiality. The manager said that all care staff receives formal supervision. This covers all aspects of their practice and training needs. They are also regularly observed in their work, and have annual appraisals. Some staff records evidence that supervision is not always happening six times a year as the standard requires. The manager should address this. The manager continues to arrange training for staff. An updated training matrix will be required as part of the home’s improvement plan. Despite the managers best efforts to develop and improve the service there continue to be significant safety risks that have been detailed elsewhere in this report. 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. Progress regarding improvements will be closely monitored. 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.V345899.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 1 2 X X 2 1 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 3 3 2 X 3 2 X 1 Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 27 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 6 (a) Requirement “The registered person shall keep under review and, where appropriate, revise the statement of purpose and service users guide” In that: Both documents must be accurate and up to date. To be completed by the given timescale, if not sooner, and maintained thereafter. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. “The registered person shall prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. The plan is to be kept under regular review” In that: 1. Whilst it is acknowledged that significant work has been completed on residents care plans they should be further developed to provide clear detail Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 28 Timescale for action 18/10/07 2. OP7 15 Schedule 3 18/10/07 direction and guidance for staff and be more person centred. 2. Daily records must clearly evidence that the demands of the care plan are being met. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. “The registered person shall 18/10/07 make arrangements for the recording, handling, safekeeping, safe administration of medicines” In that: 1. The home’s medication policy and procedures must be reviewed by the manager to ensure that medicines in the custody of the home are being handled according to the requirements of The Medicines Act 1968, Guidelines from the Royal Pharmaceutical Society, ‘Administration and Control of Medicines in Care Home’s’, The Misuse of Drugs Act 1971. 2. Hand written transcriptions and changes to MAR must be signed by a second person to confirm accuracy. 3. Staff must be regularly assessed for competency with regard to the administration of medication. 4. Written temperature records for the correct storage of medicines in the home must be maintained. 5. Storage of medicines must be reviewed in the home. The home must store medicines received into the home and awaiting return to the pharmacy in secure areas. 6. The signatory list for DS0000035711.V345899.R01.S.doc Version 5.2 Page 29 3. OP9 13(2) Mont Calm (Sturry) delegated medication administrators in the home must be current at all times. 7. Changes to resident’s medication dosage should be initialled by the prescriber on the MAR. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. Arrangements should be made to 18/10/07 enable service users to have easy access to the garden and this access should not be through the kitchen as at present. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. The uneven areas in the garden 18/10/07 and in the car park entrance area, which pose a trip hazard, must be levelled and made safe. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. The Registered person must 31/10/07 ensure that garden refuse and obsolete items of furniture and equipment are removed from the exterior grounds. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. Smoking arrangements for 31/10/07 service users must allow for adequate cover and their protection outside during DS0000035711.V345899.R01.S.doc Version 5.2 Page 30 4. OP19 13 (4) (a) & 23 (2) (o) 5. OP19 13 (4) (a) 6 OP19 23 7 OP20 23 Mont Calm (Sturry) 8. OP21 OP38 23 9. OP22 23 inclement weather. The arrangements for residents who smoke should also appear in the service users guide. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. 1. The communal Jacuzzi 31/10/07 bath must be regularly cleaned, maintained and serviced. 2. The provider must ensure that evidence is provided that the home has a risk based approach to Legionella. 3. The communal toilet mentioned in the report must be refurbished and made good. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. The Registered person must 31/10/07 ensure that the chair lift is safe and fit for purpose. Service records must be sent to the Commission. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. The Registered Person shall: 1. Provide service users with keys to their rooms unless their risk assessment suggests otherwise. 2. Each service user shall be provided with a lockable space in their bedrooms and they must also be provided with the key, which they can retain unless the DS0000035711.V345899.R01.S.doc 10 OP24 12 (4) (a) 23 18/10/07 Mont Calm (Sturry) Version 5.2 Page 31 11. OP25 OP38 13 (4) (a) 12 OP26 OP38 12(1), 13(3)(4) (c) 16(2)(j) 13. OP33 26 reason for not doing so is explained in the care plan. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. In the interest of Health and Safety all radiators and exposed pipe work should be covered to prevent accidents. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. 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 arrange for a full infection control audit of the premises by The Kent Health Protection Unit. The subsequent report of the audit will be shared with the Commission. 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. The Registered Provider must visit unannounced once a month and prepare a written report on the conduct of the home. Sending a copy of the report to the CSCI and the manager. An improvement plan detailing how the service will address this will be required within the timescale indicated. 18/10/07 18/10/07 18/10/07 14. OP36 18 (2) The Registered person must ensure care staff receives formal supervision and identification of DS0000035711.V345899.R01.S.doc 18/10/07 Mont Calm (Sturry) Version 5.2 Page 32 15. OP38 13 (4) & (5) training needs at least six times a year. Records must be kept in staff files as evidence of compliance. An improvement plan detailing how the service will address this will be required within the timescale indicated. The Registered person must ensure that statutory training and update training for all staff continues to be regularly arranged and that staff records evidence this. • An up to date training matrix clearly showing training completed, training planned and update training due for each member of staff must be provided to the Commission with the Improvement Plan. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated. 18/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 OP9 Good Practice Recommendations All service user contracts should be signed. It is most strongly recommended that the home purchase a dedicated, lockable drugs refrigerator, with minimum and maximum thermometer and temperatures should be recorded daily. DS0000035711.V345899.R01.S.doc Version 5.2 Page 33 Mont Calm (Sturry) 3. 4. OP16 OP22 5. OP33 Concerns (and compliments) should be recorded and evidence of actions taken in relation to concerns raised should be recorded. It is very strongly recommended that the registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended equipment has been secured or provided and environmental adaptations made to meet the needs of service users and to identify areas in the home that require further improvement. It is strongly recommended that the registered person further develop the quality assurance systems. Results should be shared with stakeholders and the CSCI. Mont Calm (Sturry) DS0000035711.V345899.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Maidstone Local 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.V345899.R01.S.doc Version 5.2 Page 35 - 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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