CARE HOMES FOR OLDER PEOPLE
Mount Carmel Highfields Broadway Derby Derbyshire DE22 1AU Lead Inspector
Jenny Thornton Unannounced Inspection 9th December 2005 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 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. Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Mount Carmel Address Highfields Broadway Derby Derbyshire DE22 1AU 01332 553466 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) Sisters of Mercy Trustees Sister M Flaherty Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th July 2005 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. The care home 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 DS0000001994.V269282.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was un-announced and took place over five hours. The inspector spoke to ten residents, two relatives, four members of staff, and the manager. The inspector looked around parts of the home and examined various records. All residents spoke highly of the care and services provided at the home. The home has met the requirements and recommendations from the last inspection report dated July 2005. What the service does well: What has improved since the last inspection?
The Trustees have appointed three area managers to provide support to the group homes and oversee the care and services. The home was looking to appoint a deputy manager in the New Year. The home had recently been re-assessed in regards to ‘Investors in People’ achievement, which looks at how well the home is managed. The report findings had yet to be made available but verbal feedback was very positive. Further bedrooms have been re-carpeted and decorated and the lounge chairs had been deep cleaned. The external doors had been re-varnished, and a ramp had been fitted to improve access for residents. Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 6 Improvements have been made to recording of information in resident’s care plans. Various policies, procedures and key documents had been reviewed and updated. Staff have attended various training to develop their knowledge and skills. 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 DS0000001994.V269282.R01.S.doc Version 5.0 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 Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 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 and 2 Arrangements are in place to ensure that residents or their representative are issued a written contract/statement of terms and conditions at the point of moving into the home, which safeguards their interests. EVIDENCE: The home provides a statement of purpose and service users guide for residents, which sets out the services provided and contained a good level of information. The statement of purpose required minor changes to include the age range and sex of residents, and the size of rooms. Residents had been issued a copy of the documents. Records showed that resident’s who purchased their care privately had been issued a copy of the home’s contract/terms and conditions; the provider and the resident or their representative had signed this. The home’s terms and conditions of residence were included in the statement of purpose and service users guide, and set out the facilities provided. The terms and conditions did not show the room to be occupied by the resident, and some information required updating such as the address and telephone number of the
Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 9 Commission for Social Care Inspection. The manager said that the home’s terms and conditions were due to be updated. Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 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): 10 Residents’ privacy and dignity is clearly respected. EVIDENCE: Residents praised the attitude and approach of staff and said that their privacy and dignity is respected; this was observed during the inspection. New staff were informed on induction that they must respect residents privacy and dignity at all times. Residents said that staff knock on their door and wait for permission prior to entering their room. Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 11 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): 13 and 14 Contact with family and friends is supported ensuring residents maintain links with family and friends. The home enables residents to make decisions and choices about their lives. EVIDENCE: Residents and staff confirmed that contact with family and friends is supported. Relatives said that they can visit at any reasonable time and are made to feel welcome in the home. Several residents regularly went out with their family. Residents said that they had formed good relationships with staff. Discussions with residents and observations showed that residents are helped to exercise choice and control over their lives, where possible. Residents said that the daily routines are flexible; several residents preferred to spend time in their room during the day. Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 12 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): 18 Arrangements are in place to protect residents from risk of harm or abuse. EVIDENCE: Procedures were in place to safeguard resident’s safety and welfare; the home followed Derby City’s adult protection policy and procedures. The home’s policy relating to adult protection stated that the person in charge would investigate any allegations of abuse, which is not in line with the Local Authority’s policy. The manager confirmed that there have been no allegations of abuse in the last year. The manager confirmed that eight members of staff had attended the Local Authority’s training on protection of vulnerable adults, and that all other staff had received training on the procedures as part of their induction. Staff spoken with had an awareness of the procedures. Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 13 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, 22 and 26 The environment is maintained to high standard and provides a good range of equipment providing residents with an attractive and comfortable place to live. EVIDENCE: Residents consider that the environment is comfortable and homely and is maintained to a good standard throughout; this was apparent on the inspection. A tour of the premises highlighted no issues relating to the environment; the home was clean and free from odours. Resident’s bedrooms contained personal belongings. Further improvements have been made to the environment. Further bedrooms have been re-carpeted and decorated and the lounge chairs had been deep cleaned. The external doors had been re-varnished, and a further ramp had been fitted outside the building to improve access for residents. Staff considered that the home provides a good range of equipment to meet residents and staff’s needs, including up to date bathing facilities.
Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 14 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, and 29 The home has an established staff team providing consistency of care for residents, and is appropriately staffed to meet residents’ needs. Recruitment procedures require strengthening to ensure that all the required information is obtained prior to new staff taking up post, to safeguard residents’ interests. EVIDENCE: The home has exceeded the 50 target of care staff having achieved NVQ Level 2 or equivalent. The manager confirmed that 8 out of 15 care staff had achieved N.V.Q Level 2 or 3 qualification to ensure they are trained and competent to do their job, and that two members of staff had alternative qualifications. Quite a few of the staff have worked at the home for a number of years and the home has a good skill mix of staff. The number of staff changes in the last six months remains low, resulting in residents receiving care from staff they know. Although staff sickness levels had increased over recent months, resulting in the need to use agency staff to help cover the shifts. Staff and residents considered that sufficient staff are provided to meet residents’ needs. The Inspector checked the files of two new staff; one person had yet to take up post at the home. Staff files showed that the home had obtained the
Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 15 required information and documents to safeguard residents, although the following areas required attention: • Completed application forms tended to record employment history in months and years, which does clearly show any gaps in employment. • Completed application forms contained some information relating to the applicant’s previous experience and skills. Staff files did not include a record of interview, or details of the person’s immunisation status. • The home’s policy and procedure relating to the recruitment of staff was dated October 2003, and did not include all current information and checks obtained. In line with the Trustee’s policy the manager no longer received a copy of staff’s criminal record disclosure certificate. The counter signatory provided email evidence that the person was not listed on the Protection of Vulnerable Adults list, and the manager was notified and kept a database of the date when staff’s CRB disclosure was obtained, their disclosure number and the level of disclosure carried out, which provides essential information. Staff files contained a signed statement of terms and conditions, which safeguards their interests. Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 16 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, 32 and 38 The home is run in an open and positive way, which staff and residents benefit from. The manager provides clear leadership throughout the home, which ensures that all staff have a clear understanding of their role and responsibilities. EVIDENCE: Sister Flaherty has appropriate qualifications and extensive knowledge and skills to manage the home, having worked as the registered manager for the last 14 years. The manager has a Social Work qualification and has attended a wide range of training to update her knowledge and skills, and achieved the Registered Managers award and N.V.Q. Level 4 in management. Residents, relatives and staff praised the manager’s enthusiasm, approach and ability to manage the home well and maintain high standards of care. Staff and residents said that the atmosphere at the home is relaxed and friendly. Staff found the manager approachable and said that she involved
Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 17 them in decisions about the home. Staff enjoyed their work and considered that morale was good. Senior staff have taken on specific areas of responsibility in the home, which worked well. The home had made good progress towards meeting this year’s development plan, and the manager had identified further areas for improvement for the forthcoming year. Arrangements were in place to ensure that staff attend all mandatory training. To assist in planning further training senior staff had compiled a chart, which showed at a glance what training staff had attended. Records showed that the required maintenance and safety checks were carried out. Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 18 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 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 4 X X 3 X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X X X X 3 Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Timescale for action Update the home’s statement of 31/03/06 purpose to include a summary of the room sizes, and the age range and sex of residents that can be accommodated. The home’s adult protection 31/03/06 procedures must be line with the Local Authority’s policy. The home’s recruitment policy 31/03/06 and procedure must include all information and documents obtained for staff to work at the home. Requirement 2. OP18 13 3. OP29 19 Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 20 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. Refer to Standard OP2 Good Practice Recommendations The home’s terms and conditions of residence should be updated to include all services and facilities provided including the room to be occupied by the resident. Staff applying to work at the home should be encouraged to record the full date in which they started and left previous jobs, and an explanation of any gaps in their employment. Application and interview forms should provide sufficient information about the applicant’s relevant experience and skills. The manager should record all interviews with staff to a consistent and adequate standard. Staff application forms should contain details of the person’s immunisations and current status. 2. OP29 3. OP29 4. 5. OP29 OP29 Mount Carmel DS0000001994.V269282.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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