Inspection on 15/08/06 for Montague Road Nursing Home

This inspection was carried out on 15th August 2006.

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

Montague Road Nursing Home 21/08/08

Montague Road Nursing Home 07/09/07

Montague Road Nursing Home 01/02/06

Montague Road Nursing Home 14/11/05

Montague Road Nursing Home 31/01/05

Montague Road Nursing Home 28/07/04

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

CARE HOMES FOR OLDER PEOPLE Montague Road Nursing Home 14 Montague Road Felixstowe Suffolk IP11 7HF Lead Inspector Jane Higham Unannounced Inspection 15th August 2006 09.55 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 Montague Road Nursing Home DS0000024450.V306888.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. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Montague Road Nursing Home Address 14 Montague Road Felixstowe Suffolk IP11 7HF 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) 01394 670111 01394 276021 Orbit Housing Association Mrs Anne Amelia Scott Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (24), Mental Disorder, excluding learning disability or dementia - over 65 years of age (24) Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st February 2006 Brief Description of the Service: Montague Road is a 24 bedded residential home with nursing, providing care and accommodation to older people who suffer from either organic or functional mental health problems. The home was initially registered in April 1993 and is purpose built, sited in a residential area of Felixstowe, close to both the town centre and sea front. All admissions to the home are via the Social Care Services Department due to the joint funding arrangements with Orbit Housing Association who staff and administer the premises. Living accommodation is sited on two floors and is divided into three main living areas. Each of these consists of eight bedrooms with ensuite facilities, a communal bathroom, toilets and a lounge and kitchen /dining room. A secure garden surrounds the building and there is limited car parking to the front. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Key inspection of 14 Montague Road, a twenty-four bedded care home with nursing for up to twenty four service users, over the age of 55, who have either organic or functional mental health needs. The home is owned and administered by Orbit Housing Association in conjunction with Social Care Services and is sited in the coastal town of Felixstowe, close to both the town centre and seafront facilities. The inspection was carried out on 15 August 2006, over a period of seven and a half hours. The key inspection focused on the care standards relating to Care Homes for Older People. The report has been written using accumulated evidence gathered prior to and during the inspection. Prior to the inspection, the home was provided with both service users and relatives/visitors questionnaires for distribution. At the time of writing, one questionnaire had been returned to the Commission, the contents of which have been reflected in this report. The National Minimum Standards and Care Homes Regulations 2001 are referred to throughout this report and any non compliance identified. All key standards were assessed as part of this inspection. The Registered Manager of the home was present throughout the inspection and assisted with the inspection process. The Inspector had the opportunity to talk to both residents and staff members during the inspection. What the service does well: The home provides a specialist service for residents who have severe longterm mental health needs. As such the home has a very detailed preadmission assessment process in order to ensure that it can meet the needs of any prospective service user. Each service user is provided with a plan of care which provides a clear breakdown of their assessed needs and identifies the level of intervention and support required to ensure that those needs are met appropriately. The home ensures that both the physical and emotional health needs of residents are monitored and where necessary community health resources are accessible. The home provides a high standard of accommodation which is maintained to a good standard of decorative order and repair. Accommodation is very spacious and unrestrictive and provides residents with a very homely and relaxed environment in which to live. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Montague Road Nursing Home DS0000024450.V306888.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 Montague Road Nursing Home DS0000024450.V306888.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Residents living at the home and their representatives could not necessarily expect to be provided with a current and up-to-date Statement of Purpose. However, residents and their families can be assured that the home will be able to meet their individual needs which are identified through a robust and detailed pre-admission assessment process. Residents and their families will not necessarily receive a copy of the terms and conditions of placement. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was able to evidence that it had a combined Statement of Purpose and Service User Guide. This is a very informative and comprehensive document providing information about the services and facilities provided. The document is provided to prospective residents and their families who have been offered a place at the home. The Inspector recommended that a copy of the Statement of Purpose and Service User Guide is placed in the reception area of the building so that it is available to all visitors. The document contains Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 9 all required information in compliance with the Care Homes Regulations 2001, including a specimen contract and information on how to make a complaint about the service. The current Statement of Purpose and Service User Guide was issued in September 2004 and does not correctly reflect the home’s current registration. The document states that the home provides accommodation and care to people over the age of 55 “who suffer from severe mental and/or physical infirmity”. This would imply that the home is able to accommodate service users who suffer from a physical disability alone. Additionally the home accommodates service users over the age of 55 who suffer from a mental disorder. The Inspector was informed that the Statement of Purpose and Service User Guide was currently being updated and therefore needs to include the above information. As part of the inspection process, the Inspector examined the admission information for the three most recently admitted service users. Due to the joint funding arrangement, all admissions to the home are accessed via the Social Care Services Department. In all three cases the home was able to evidence that prior to admission taking place a detailed Community Care Assessment had been completed by the named assessor and considered by the Manager. Additional information had also been provided by hospital mental health services. Whilst the Manager advised that the home also carried out its own pre-admission assessment, documentation to evidence this was not available. All three service users had been provided with an individual placement contract issued by the local authority but the home was unable to evidence that the owning organisation had issued residents or their representatives with a contract which contained the terms and conditions of residence. At the time of the inspection, the current range of fees were £755 - £855 per week. The home has one respite care bed, which is shared by the Social Care and Health services. The home does not offer intermediate care. Montague Road Nursing Home DS0000024450.V306888.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents living at the home can expect to be provided with a plan of care which identifies their individual needs and levels of support and active assistance required. Residents can expect both their physical and mental health needs to be met and to be enabled to access community health services. Residents are protected by the home’s policies and procedures on the administration and safe keeping of medication. Practices in relation to the wording of care plans and the storage of continence aids did not evidence that residents were treated with respect and their privacy protected at all times. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: For the purposes of the inspection, the Inspector examined the individual care plans for the three most recently admitted service users. A daily living assessment had been completed for each person from which a care plan was derived which identified the individual levels of support required in order for each service user to meet certain objectives. In the main, daily living Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 11 assessments were detailed in their content and gave a clear breakdown of the assessed needs of each person. Staff at the home need to be reminded that these documents require dating at the time they are written. The home was able to evidence that care plans were up to date and had been reviewed on a regular basis. Care Plans also included information on preferred forms of address and preferred daily routines. Two of the three care plans seen were detailed in their content and provided a clear picture of the individual assessed needs of each person. The other care plan was somewhat limited in its information. The home was able to evidence that moving and handling assessments are completed for each person as part of the care planning process. In the case of one of the service users selected for the purposes of care tracking, the home was able to evidence that a comprehensive risk assessment had been completed. However, in the case of the other two service users, despite pre-admission assessments identifying risks including aggressive and challenging behaviour, a risk assessment had not been completed as part of the care planning process. It was noted that in one care plan a member of staff had made reference to the “removal of privileges” if a resident was non compliant with certain continence routines. This language is wholly inappropriate and did not evidence that the service user was afforded respect at all times. The three care plans selected for the purposes of care tracking evidenced that both the physical and mental health of residents was monitored. Where appropriate, service users were supported and enabled to access community health services such as domiciliary visits by GP services. Records of GPs visits were maintained which identified the reason for the visit, the outcome of the visit, any medication change and a review date. Records also evidenced that residents are supported to access outpatient hospital services and clinical guidance is derived from the area mental health hospital services. For the purposes of the inspection, the Inspector observed medication being administered to residents during the mid-day meal on one of the living units. Each unit has a fit for purpose medication trolley, which when not in use is locked away securely in a cupboard. Resident medication was administered by the Deputy Manager who was a registered nurse and is dispensed from pharmacy supplied blister packs. Medication was administered appropriately and Medication Administration Records completed correctly on each occasion. It was noted that in addition to the blister packs other prescribed medication was stored appropriately within the trolley. However, the trolley also stored some items of prescribed medication which had been removed from its original packaging and therefore did not have a pharmacy label attached. Two items which come under “Homely Remedies” were stored in the medication trolley. These items should be labelled with the name of the service user for whom they have been purchased and a record maintained of their administration. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 12 All service users are provided with ensuite toilet facilities which assists in ensuring that their privacy is protected. All bedrooms doors are fitted with a privacy lock, which has an override device to allow access in an emergency. Care plans indicated that the preferences, likes and dislikes of residents are noted and recorded. Staff were observed knocking on the doors of residents’ rooms before entering. Whilst looking around the accommodation, the Inspector noted that a clean incontinence pad had been left on the bedside cabinet in the room of one resident. This practice did not ensure that the privacy and of the service user was protected at all times. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14 and 15 Residents living at the home can expect to be offered a range of meaningful activities and enabled to maintain contact with family and friends. Residents can expect likes, dislikes and preferences to be acted on and to be provided with a diet which is both nutritious and varied. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, six residents were setting off on a day’s outing to Easton Farm Park. They were accompanied by six members of staff, providing a one to one support service. A forthcoming barbeque was being advertised at various sites around the building as was a musical entertainer who was visiting the home in the near future. It was reported that during the previous week, some residents had enjoyed a trip to Felixstowe and another outing was planned for the following week. The Activities Co-ordinator had just returned from long term sick leave and therefore the provision of a planned programme of activity had been somewhat limited as this area of service provision had had to be covered by care staff. However, there are now two activities coordinators employed by the home offering a total of 20 hours resident activity per week. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 14 The home is conveniently located near to both the town centre of Felixstowe and the sea front and residents are supported to access these local facilities and resources. The home has an open visiting policy and residents are welcome to entertain their visitors within the privacy of their own bedrooms or in one of the many communal seating areas sited around the building. For the duration of the inspection there were no visitors to the building. Resident care plans seen at the time of the inspection, evidenced that their preferences in relation to their everyday lives, preferred routines , dietary requirements and preferred form of address are noted and acted upon. During the inspection, the Inspector observed the meal being served on Wren Unit. Three residents were enjoying lunch on this unit as their colleagues had gone on the outing. When asked, the three residents confirmed that they had enjoyed their lunch. Menu choices for the day were displayed on a chalkboard on each unit. No concerns have been raised in relation to the standard of meal provision and inspections have continued to identify that this area of service provision is of a good standard. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents and their representatives can expect to be provided with sufficient information to enable them to make a complaint or raise any concerns they may have about the service. The homes policies and procedures protect residents from the risk of abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was able to evidence that it has a complaints procedure which is produced by the owning organisation, a copy of which is displayed within the building. The Statement of Purpose and Service User Guide also provides information on how service users or their representatives can make a complaint or raise any concern they may have. The one relative/visitor card returned to the Commission prior to the inspection, indicated that the respondent was aware of the home’s complaints procedure. The home has a copy of the local authority Protection of Vulnerable Adults procedure and was able to evidence that all staff have received training in the recognition and reporting of abuse. Since the previous inspection, the Commission has received no complaints in relation to this service. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 16 Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Residents can expect live in accommodation which meets their individual needs, is maintained to a good standard of decorative order and repair, is comfortably furnished, clean and hygienic and provides a homely atmosphere. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is divided into three living units each accommodating eight service users. In addition to bedroom facilities which are all for single occupancy and have the benefit of an ensuite (some with shower), each living unit has its own lounge, dining room, kitchen and communal bathroom, with assisted bathing. There are two living units on the ground floor and one on the upper floor which can be accessed via a stairway or passenger lift. To the front of the building there is a large reception area, with comfortable seating, where residents can sit and watch the “comings and goings” of the home. Leading off the reception area there is a spacious communal lounge where larger home’s functions can Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 18 be held and where residents can spend some “quiet time” if desired. All units have unrestricted access into the home’s secure gardens which are very attractive and maintained to a high standard. On the day of the inspection, the Inspector undertook an environmental tour of all three living units and looked at a selection of resident bedrooms. These were maintained to a good standard of decorative order and repair and good use had been made of attractive soft furnishings. Ensuite facilities were well equipped with a minimum of wash basin and toilet, although some also included a shower facility. Many of the rooms seen had been made to look very personal by the occupant with the addition of small items of personal furniture, pictures and photographs. Several of the bedrooms seen had televisions and music centres. Rise and fall beds had been provided where required and several of the service users had been provided with pressure relieving mattresses. It was identified on the day of the inspection that a large box stored on top of a wardrobe in a bedroom located on Kingfisher Unit, constituted a health and safety risk to the occupant. All communal areas of the home were very comfortably furnished and maintained to a good standard of decorative order and repair. All areas of building were maintained to a good standard of cleanliness and hygiene. Care staff spoken to on Wren Unit commented that the home had good infection control procedures. In summary, the home provides a high standard of accommodation for service users, which provides a homely and relaxed atmosphere. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Residents living at the home can expect to be supported and cared for by an appropriate level of staff to meet their individual needs. Residents can also expect staff to carry out their roles in a competent and informed manner. Residents can not necessarily expect their individual mental health needs to be met by care staff. Residents are protected by the home’s recruitment procedures. Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, the home was being staffed by the Manager who was on duty in a supernumerary capacity, two qualified nurses, one of whom was the Deputy Manager and four members of care staff. Two members of staff are allocated to each living unit to meet the individual needs of the eight service users living there. This staffing level is available throughout the working day and during the night period, residents are cared for and supported by one qualified nurse and three members of care staff. On the day of the inspection additional staffing had been secured in order that a group of six residents could be accompanied, on a one to one basis, on a days excursion to a local farm park. Whilst the current level of staffing is considered adequate to meet the needs of the resident group, on two occasions the Inspector noted that only one staff member was available on Robin Unit, owing to a staff member leaving the unit to take a break. The Manager advised that a clear Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 20 procedure was in place where care staff wishing to leave the unit, for what ever reason, must request cover from another staff member to ensure that two staff members are available to assist and support residents at all times. The home is a specialist residential resource which aims to meet the needs of residents over the age of 55 who have either organic or functional mental health needs. That being so, the home ensures that a qualified nurse is on the premises at all times. Additionally, 15 members of care staff had achieved an NVQ Level 2 qualification in care. Evidence was available to show that all newly employed care staff are provided with an in-house induction training programme. Newly employed care staff who have not had previous experience are provided with a structured Induction Training package which complies with Skills for Care training targets. The Manager advised that this training is purchased by the owning organisation but is not necessarily acquired during the first six weeks of employment as dictated by Standard 30 of the National Minimum Standards. Whilst the Manager confirmed that all care staff are provided with mandatory training which included areas such as moving and handling and fire safety, overall training records for staff were not available to evidence this. Inspections undertaken by the Commission on 31/01/05, 14/11/05 and 01/02/06 have highlighted the fact that whilst the home provides a specialist residential service for adults over the age of 55 who have a diagnosis of dementia, care staff have not been provided with a formal training package on the care of older people with dementia. In order to ensure that the home is able to meet the needs of this service user group, who have been assessed as requiring psychiatric nursing input, it is of utmost importance that care staff undertake this training. The Manager reported that the home is about to purchase a distance learning work pack, from the Alzheimer’s Disease Society, for each member of the care staff. As part of the inspection process, the personnel files of the two most recently employed members of staff were examined. These files evidenced a clear employment and interview process and confirmed that two written references are secured for any prospective member of staff prior to the commencement of duties. In the case of one newly employed staff member, the home was able to evidence that both a POVA Check and Enhanced Disclosure via the Criminal Records Bureau had been secured. In the case of the second staff member, evidence of a POVA Check and Enhanced Disclosure were held by the organisation’s head office and had to be forwarded to the home by e-mail. The one comment card returned to the Commission by a relative/visitor, confirmed that in their opinion there were sufficient staff on duty. The respondent made an additional comment on how kind and caring they found the staff. A member of agency staff working at the home on the day of the inspection, commented on how much they enjoyed working at this particular home and that there was good communication between staff members. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 21 Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Residents can expect to live in a home that is appropriately and effectively managed. Residents and their families can not necessarily expect to be directly consulted about the quality of the services provided but can be assured that their finances are securely and appropriately managed. Residents can expect that their health, safety and welfare is protected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was not immediately able to provide the Inspector with an up to date list of residents who were being accommodated. The validity of this list is particularly important in the event of a fire. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 23 The home is managed by Mrs. Annie Scott who took up the post some six years ago. Mrs. Scott is a registered Mental Health Nurse and is currently undertaking the Registered Manager Award. The one visitor/relative comment card returned to the Commission commented that standards at the home are very high thanks to the Manager. Whilst the home was able to evidence that the monthly quality assurance visits required under Regulation 26 of the Care Homes Regulations 2001 take place, there were no other measures which actively sought feedback from service users or their representatives. No support groups were currently offered for relatives whose family member suffered from dementia. The home currently offers eight places for residents who suffer from a functional type mental disorder who would be able to provide feedback about the services provided. The Manager informed that no relative questionnaires had been distributed recently. As part of the Inspection process, the Inspector examined the procedures for the administration and safe keeping of resident finances for two of the service users selected for the purposes of case tracking. As in previous inspections, the homes administrator was able to evidence that they maintained appropriate records for any transactions made on behalf of service users or where service users wished to draw cash out. Amounts of cash for each service user were held separately and securely and tallied with the amount recorded on the accompanying transaction sheets. The Administrator reported that a weekly audit of resident finances is undertaken, although there was no entry on transaction sheets to evidence this. Appropriate records were available to evidence that fire alarms were tested on a weekly basis and emergency secondary lighting on a monthly basis. The home was able to produce a valid Gas Safety Certificate but the Electrical Safety Certificate was held by the organisation’s head office and not available for inspection. The home was able to evidence that all portable electrical appliances had been tested over three days prior to the inspection. All accidents and incidents occurring in the home were documented and a copy forwarded to the Commission under Regulation 37 of the Care Homes Regulations. Care Plans examined for the three service users selected for the purposes of care tracking showed that despite risks being identified as part of the pre-admission assessment documentation, an individual risk assessment in relation to daily living at the home had not been produced in the case of two residents. Temperatures of hot water delivered to outlets accessible by service users were at a safe and appropriate temperature. Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 24 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation Sch. 1 Requirement Timescale for action 11/09/06 2 OP9 13(2) 3 OP9 13(2) 4 OP10 OP18 12 The Registered Persons must ensure that the home’s Statement of Purpose correctly reflects its current registration and the category of service users accommodated. The Registered Persons must 11/09/06 ensure that that all prescribed medication, not administered via a monitored dosage system, remains in it original packaging with the pharmacy label attached. The Registered Persons must 11/09/06 ensure that any “homely remedies” which are stored in the medication trolley are labelled with the name of the service user for whom they have been purchased and a record maintained of their administration. The Registered Persons must 15/08/06 ensure that punitive measures are not used in relation to service users who are non compliant and must ensure that residents are respected at all times. DS0000024450.V306888.R01.S.doc Version 5.2 Montague Road Nursing Home Page 26 5 OP24 13(4) 6 OP27 18(1)(a) 7 OP29 Sch.2 8 OP30 18(1)(c) 9 OP30 18(1)(c)(i ) The Registered Persons must ensure that a large box stored on top of a wardrobe in a bedroom on Kingfisher Unit is removed as it constitutes a health and safety hazard. The Registered Persons must ensure that a sufficient staffing is provided on each living unit when allocated staff take breaks The Registered Persons must ensure that evidence is available at the home to confirm that all employees have been subject to a POVA Check and Enhanced Disclosure. The Registered Persons must ensure that the home maintains an up to date record of training undertaken by each member of staff. The Registered Persons must ensure that care staff receive training in the care of older people with dementia. This is a repeat requirement from 31/01/05, 14/11/05 and 01/02/06. 16/08/06 15/08/06 16/08/06 25/09/06 14/10/06 10 OP33 12(3) 11 OP38 13(4)(b) The Registered Persons must ensure that a quality assurance system is in place which actively seeks feedback from service users and/or their representatives. The Registered Persons must ensure that risk assessments are produced for all residents in relation to any risk identified as part of the pre-admission assessment. This is a repeat requirement from 14/11/05 and 01/02/06 15/10/06 18/09/06 Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 27 12 OP38 23(4)(c) 13 OP38 13(4) The Registered Persons must 15/08/06 ensure that an up to date list of residents accommodated at the home is maintained. The Registered Persons must 16/08/06 ensure that it has a valid Electrical Safety Certificate which is available for inspection. A copy must be forwarded to the CSCI. 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 3 Refer to Standard OP2 OP7 OP10 Good Practice Recommendations The Registered Persons should ensure that all residents or their representatives are provided with a copy of the terms and conditions of residence. The Registered Persons should ensure that all elements of individual care plans are signed and dated by the author. The Registered Persons should ensure that in order to protect the dignity of residents, incontinence aids are stored away in a cupboard or drawers within the service users room. The Registered Persons should ensure that all newly employed care staff undertake an Induction Training Package which complies with Skills for Care training targets within the first six weeks of employment. The Registered Persons should ensure that the weekly audit of service users finances is evidenced. 4 OP30 5 OP35 Montague Road Nursing Home DS0000024450.V306888.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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