Inspection on 28/07/05 for Mount Carmel

This inspection was carried out on 28th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Mount Carmel 29/06/09

Mount Carmel 13/06/07

Mount Carmel 09/12/05

Mount Carmel 21/12/04

Mount Carmel 13/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Mount Carmel Care Home Highfields Broadway Derby DE22 1AU Lead Inspector Jenny Thornton Unannounced 28 July 2005 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 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. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mount Carmel Address Highfields Broadway Derby DE22 1AU 01332 553466 01332 550122 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sisters of Mercy Trustees Sister Mary Flaherty Care Home 20 Category(ies) of Older People registration, with number of places Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21/12/04 Brief Description of the Service: Mount Carmel House is a single storey purpose built home providing personal and social care for 20 people aged 65 years and over . Mount Carmel House is located off the Broadway in Derby. All bedrooms are single rooms with ensuite facilities. The home has several small sitting areas, a smoking room, conservatory and a dining room. The home has well set out gardens and seating areas. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and started at 10am. The visit lasted 6.5 hours. The Inspector spoke to the manager, twelve residents, two relatives and four members of staff. The Inspector looked around the home and examined various records. All residents spoke highly of the care and services provided at the home. Arrangements are in place to ensure that the home is well run and that resident’s needs are met. What the service does well: What has improved since the last inspection? Further improvements have been made to residents care plans. Procedures for the safe keeping and handling of medicines have been strengthened. Further areas have been decorated. Lights and grab rails have been fitted around the walking areas outside to make it safer for residents. Staff have attended a good range of training and further care staff had achieved Level 3 N.V.Q. qualification. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 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 standard(s) 3 and 4 Arrangements are in place to ensure that residents’ needs are fully assessed and met prior to and following admission to the home. Residents’ needs are well met by a committed and well-trained staff team. EVIDENCE: Two care plans examined contained a good level of information about individuals needs, and included a pre-admission assessment. Staff had completed various risk assessments, which highlighted risks to residents and measures taken to minimize risks where identified. Not all risk assessments had been signed and dated by the member of staff completing them. This was highlighted on the previous inspection report. Risk assessments were being reviewed. A new form had been produced to record information about service users wishes concerning terminal care and arrangements in the event of their death, which was well completed. Residents had formed good relationships with staff. Residents said that the staff are very caring and can’t do enough for them. Residents considered that Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 9 their needs are well met, and relatives shared this view. The staff team have considerable experience and were attending a good range of training to ensure they have the skills to care for residents. Staff showed a good understanding and a commitment to meeting individual needs. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 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 standard(s) 7,8,9 and 10 Procedures are in place to ensure that residents’ health and personal care needs are met, and care plans clearly set out how needs were being met. Procedures for the safe keeping and handling of medicines have been strengthened to safeguard residents’ welfare. EVIDENCE: Two care plans checked were detailed and set out how resident’s needs were being met. Care plans had been updated following changes in resident’s needs, care or treatments, although one resident’s care plan had not been amended to include the current protective spray applied to his pressure areas. The manager agreed to address this. Residents had signed to say that they had been involved in completing their care plan. Staff had completed a monthly progress report on resident’s needs, which reported on all aspects of their care plan. Essential information and incidents involving residents were recorded. Staff also recorded a statement three times a day in each resident’s kardex, which was both time consuming and resulted in repetition of information. The manager agreed to review this practice. The medical needs sheet was not signed or dated, and did not provide sufficient space to record the strength dose and the frequency of all medicines a resident was taking at Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 11 the time of admission to the home. The manager agreed to update the form to include this information. Discussions with residents and staff and care plans examined showed that resident’s health and personal care needs are well met. Arrangements are in place to enable residents to be seen by an optician, dentist and chiropodist on a regular basis. Records showed that staff accessed professional advice and support for residents, where required. Visits from health professionals such as G.P.’s were clearly recorded in residents care plan. Residents said that their privacy and dignity is respected; this was observed throughout the inspection. Work has been carried out to address the medication issues identified on the last inspection report, to ensure that medicines are appropriately handled. All staff that administers medicines at the home had received training from a competent person. Policies and procedures were in place relating to the ordering, receipt, storage administration, and disposal of medicines in the home, which staff had been made aware of. Medication administration records checked had been duly signed. The dispensing pharmacist printed the majority of medication administration records. A couple of medicines that had been handwritten onto resident’s medication administration records, did not record the quantity of medicines received, and had not been signed by the member of staff completing the record, or checked and counter signed by a second member of staff. Staff are required to record this information to provide an audit trail of medicines in the home. The manager took action to address this issue. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 and 15 The home provides a good variety and choice of home cooked foods, which residents enjoy. Importance is given to ensuring that residents maintain personal choice and control over their lives. EVIDENCE: From discussions with residents it was clear that they are helped to exercise choice and control over their lives, and are encouraged to handle their own finances for as long as they wish, and are able to do so. Information on how to contact external advocates to act on a resident’s behalf, was not available to residents and their relatives and friends. All residents spoke highly of the meals provided at the home and said that their needs and preferences were met. Residents said that the meals include home cooked foods, which they enjoy. Residents consider that the meals are of a good quality, offering both choice and variety. Catering staff carry out all food preparation and catering duties, which enables care staff to care for residents. All food supplies were of a good quality. The dining room tables were suitably set. A couple of residents had recently raised that they would prefer to have separate dining tables instead of the tables in a line, the Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 13 manager reported that this had been looked into but due to the size and layout of the dining room it was difficult to set the tables out individually. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Complaints about the care and services are viewed positively and complaints received are well managed and acted upon. EVIDENCE: The home has a clear complaints procedure, which was displayed in the home and included in the service users guide. Relatives and residents said that they were aware of the complaints procedure, and considered that staff are approachable and that concerns are listened to and acted upon. Three complaints had been received since the last inspection; the records showed that the complaints had been acted upon, although the outcome of the complaints was not always recorded. Records of complaints included those from residents and staff; the records were not kept confidentially. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The environment is of a high standard and provides residents with a homely and safe environment to live in. EVIDENCE: All residents considered that the environment is comfortable and homely and is maintained to a high standard throughout; this was apparent on the inspection. A tour of the premises highlighted no issues relating to the environment. Arrangements were in place to ensure that the home is well maintained. Further areas have been redecorated since the last inspection. Resident’s bedrooms contained personal belongings and reflected individual’s preferences. Some residents preferred to spend time in their room, whilst other residents made good use of the lounge areas throughout the house. The home has well set out garden and seating areas, which residents enjoyed spending time in when the weather is good. Lights and grab rails have been fitted around the walking areas outside the home to make it safer for residents. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The home provides consistency of care and a good skill mix of staff to meet residents’ needs. Staff receive a good range of training to ensure they have the skills to care for residents. EVIDENCE: Residents, relatives and staff spoken with considered that sufficient staff were provided to meet residents needs. The home continues to have a low turnover of staff and had a full team of staff, which results in residents receiving care from staff they know. To cover annual leave and staff absences the home used agency staff support on occasions. To ensure continuity of care for residents the home used two Agencies and the same agency staff, where possible. The manager received written confirmation from the employment Agencies that satisfactory Criminal Record Bureau Disclosure and in some cases written references had been obtained for agency staff working in the home. The procedures in place did not ensure that all the necessary information and documents have been obtained for agency staff to work in the home, in order to safeguard residents interests. Staff spoken with said that the home provides good training opportunities, and that they had attended a good range of training. Records confirmed this. The home had a clear annual training plan, which was displayed in the home. In addition to all the mandatory training, staff had received training on management of continence, skin care, nutrition, complementary therapies, Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 17 challenging behaviour, and caring for people with dementia and Parkinson’s disease. The manager confirmed that further care staff had achieved a national approved qualification (N.V.Q Level 3), to ensure they are trained and competent to do their job. The home is to be commended on the level of training provided for staff in the last year. All staff had an individual record of training they have attended, included copies of certificates from courses. A member of staff who recently started had completed the home’s induction programme, which was reported to be in line with national training requirements. Newly appointed staff had completed further training, although this was not set out in a training programme. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35 The arrangements in place for consulting with residents are good and residents’ views are actively sought and acted upon. Arrangements are in place to safeguard resident’s financial interests and handling of residents’ money. EVIDENCE: Importance is given to planning and development to ensure the home is well run. The home had a clear annual development plan, and has made good progress towards meeting the aims set out in this year’s plan. Staff said that the manager involves them in decisions about the home. Residents consider that the home is run around their needs and that their views are actively sought and acted upon. Procedures are in place for monitoring the care and services provided at the home. The results of a recent satisfaction questionnaire issued to residents and visiting professionals had been published; this showed that the home was providing a high standard of Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 19 care and service. Various suggestions made in the satisfaction questionnaires had been acted upon, such as changes to the meals and displaying a menu in the home. The home had a policy and procedure relating to the management of residents finances and money. The manager confirmed that resident’s, relatives or an independent person managed their finances and personal allowance. At the time of the inspection seven residents had a small sum of money in safe keeping at the home. Appropriate records were kept of money in safekeeping to safeguard resident’s interests. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 4 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x 3 x x x Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? 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 9 Regulation 13 Requirement Medication administration records that are handwritten must record the quantity of medicines received, and be signed and dated by the member of staff completing the record, and checked and counter signed by a second member of staff. The registered person must obtain evidence that all information and documents listed in Schedule 2 of the Care Homes Regulations have been obtained in regards to agency staff working in the home Timescale for action 31 August 2005 2. 29 19 30 September 2005 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 3 7 14 Good Practice Recommendations All assessments forms relating to residents should be signed and dated Staff should consider the purpose of recording daily entries in residents care plans and reduce the repetition of information. Information should be made available to residents and C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 22 Mount Carmel Care Home 4. 5. 16 30 their relatives and friends on how to contact external advocates to act on a resident’s behalf. Records of complaints should be kept confidentially. The registered manager should ensure that the staff induction programme covers all the current standards, as outlined in Skills for Care revised induction programme. Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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. Extracts may not be used or reproduced without the express permission of CSCI Mount Carmel Care Home C52 C02 S1994 MountCarmel V235209 280705 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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