Inspection on 26/04/05 for Mount Denys

This inspection was carried out on 26th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Denys 26/11/07

Mount Denys 30/05/06

Mount Denys 10/11/05

Mount Denys 19/11/04

Mount Denys 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Mount Denys 187 The Ridge Hastings East Sussex TN34 2HE Lead Inspector Judy Gossedge Unannounced 26 April 2005 12:00 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 Denys Version 1.10 Page 3 SERVICE INFORMATION Name of service Mount Denys Address 187 The Ridge Hastings East Sussex TN34 2HE 01424 421353 01424 421925 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) East Sussex County Council Mrs Maureen McAdam Care Home 31 Category(ies) of Dementia over 65 years of age DE(E) 31 registration, with number of places Mount Denys Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of thirty-one (31) service users to be accommodated. 2. That service users must be aged sixty-five (65) years or over on admission. 3. That only service users with a dementia type illness are to be accommodated. 4. That five (5) places will be available for service users between the age of fifty-five (55) and sixty-four (64). 5. That one named service user who has been assessed as requiring nursing care be accommodated. 6. That one named service user with mental health issues can be accommodated. Date of last inspection 19 November 2004 Brief Description of the Service: Mount Denys is a purpose built property run by East Sussex County Council (ESCC) on two floors, adjacent to Pinehill Day Care Centre on the outskirts of Hastings, approximately two miles from the town centre. Mount Denys operates as a specialist service for older people with dementia in Hastings and Rother. Bexhill and Rother, and Hastings and St Leonards Primary Care Trusts commission the service, with the care managed by ESCC. Service user accommodation comprises of thirty-one single bedrooms on three units within the home. Two units of ten beds and one unit of eleven beds which provide accomodation for a mixture of long, short stay, respite and periods of assessment. Each unit has a dining and lounge area for service users to use. There are sufficent toilet facilities and assisted bathing facilities on each of the units. Additionally there is a large lounge area on the ground floor. There is level access facilitated in the home with the provision of a passenger lift. There is a garden at the rear of the home with a walkway and seating areas which service users can access. Mount Denys Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five hours on 26 April 2005. A monitoring visit had also been carried out on 14 March 2005 to review compliance with requirements. A partial tour of the premises took place including communal areas and a selection of service users bedrooms. Rotas and care records were also inspected. Two of the twenty-six service users were spoken with individually in the communal areas. Due to communication difficulties it was not possible to speak to all service users individually, and so the opportunity was also taken to observe the interaction between staff and service users in the communal areas. The Manager and eight care workers, two housekeeping staff and the cook were spoken with. Two relatives, regular visitors to the home were also spoken with by telephone after the inspection. What the service does well: What has improved since the last inspection? The standard of décor, carpeting and furnishings are generally poor in the majority of the home. Since a requirement was made following the last Mount Denys Version 1.10 Page 6 inspection a review has been undertaken and a plan of redecoration has been drawn up for this financial year 2005/2006. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mount Denys Version 1.10 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 Denys Version 1.10 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) 1, 3 and 6. There is detailed information about Mount Denys available to be viewed prior to any admission to the home. There are pre-admission procedures in place to ensure that service users on planned admissions are appropriately placed at Mount Denys. EVIDENCE: A detailed Statement of Purpose and Service Users Guide is available to view with other supporting information in the entrance to the home. One relative who had been visiting at the home for a period of time confirmed that they were aware of this information and also had had access to the inspection reports. There are forums for service users and carers to give their views on the service received. This feedback has not been collated for prospective service users and their carers to view and assist with their choice of home. Prior to admission to the home service users are assessed primarily by the Community Mental Health Team, or a Social Care Assessment is completed by staff from one of ESCC Social Services Department’s Assessment Teams. A copy of the assessment is then forwarded to the home. There was only one new service user at Mount Denys at the time of the inspection and the preMount Denys Version 1.10 Page 9 admission information had been received. Staff confirmed that they had also visited the service user prior to admission to gain information to help them provide the required care. Where two service users care needs have changed a variation to the current registration in place is being considered. Intermediate or rehabilitative care is not provided. Mount Denys Version 1.10 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 and 9. Individual care plans provide staff with the information they need to ensure that care needs are met. ESCC has detailed policies and procedures in place to manage medicines which need to be followed to ensure the protection of service users. EVIDENCE: Using the initial assessment of need individual plans of care are compiled for each service user; these identify amongst other things what support is required from staff to meet their day to day needs in relation to health, personal and social care needs. A selection of these care plans were examined; improvements continue to be made to the detail of these plans. Telephone conversations with two relatives confirmed that they had either attended meetings or staff had kept them informed about the care provided. It was observed during the inspection that personal care is provided with dignity and respect. Service users and relatives spoke very well of the care provided by staff in the home. Medication policies and procedures in place are in the process of being reviewed. Staff were in the process of receiving further medication training during the inspection. The storage and a sample of the recording of the Mount Denys Version 1.10 Page 11 administration of medication was viewed, and on one unit the process of administration was also observed. A number of omissions in the recording of administration of medication were seen. This was discussed with the Manager and an Immediate Requirement Form was left for this issue to be addressed. Mount Denys Version 1.10 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) 12,13, and 15. Service users are encouraged and supported to participate in the activities provided. There is flexible visiting in the home and visitors to the home are welcomed. The meals in the home offer both choice and variety and special dietary needs can be catered for. EVIDENCE: Four service users went out on a mini bus trip during the morning of the inspection. Two service users were heard to comment that they had enjoyed the trip out. During the afternoon a small group of service users were seen to be involved in a word game in the large lounge. There is no set activities plan in place but activities are largely lead by what the service users wish to do on the day. Three care staff spoken with who help provide activities, confirmed that one member of staff is on duty daily between 9.00- 4.00 who facilitate a range of activities in the large lounge. The two service users confirmed that activities take place. Service users on the upstairs unit were not involved in an activity on the afternoon of the inspection, which it was understood was the service users choice. Service users on this unit have been observed on previous inspections participating in various activities. Mount Denys Version 1.10 Page 13 Both service users and relatives spoken with confirmed that there is flexible visiting at the home, and that staff are always welcoming. An independent supplier of frozen foods is used to provide the lunch in the home. A rotating menu which is seasonally varied was seen. Staff had made a selection from the menu for service users at lunch time. Staff spoke of an awareness of individual likes and dislikes of meals provided and of the different textures of food which has been observed over a period of time, thereby allowing them to make appropriate choices where a service user is not able to do this for themselves. Special diets are catered for, and the cook commented that a request had been made for further advice on some special diets to enable a wider variety of dishes to be provided. A system of recording individual service users meals had not always been maintained which is important for staff to ensure that service users dietary needs continue to be met. The two service users spoke well of the food provided. Mount Denys Version 1.10 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. There is a clear and effective complaints procedure in place. EVIDENCE: ESCC has a detailed compliments and complaints policy and procedure in place. Any complaints received are monitored through the line management arrangements in place within the organisation. One complaint made by a relative was recorded in the complaints log since the last inspection, which was satisfactorily investigated. Both service users and relatives spoken with confirmed that if they would feel comfortable raising any concerns, and that they would raise these with their key worker or the Manager in the home. Mount Denys Version 1.10 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, 25 and 26 The standard of the environment is generally poor and does not provide service users with a safe, attractive and homely place to live. The home is clean and free from odours. EVIDENCE: The standard of décor, carpeting and furnishings are generally poor in the majority of the home. Since a requirement was made following the last inspection a plan of redecoration has been drawn up for this financial year 2005/2006. Comments from the relatives were that there was a ‘homely atmosphere’ in the home, but that the environment was not ‘so homely’. There are thirty-one single bedrooms of which twenty do not meet the minimum space requirements. Service users are unable to control the temperature in their own bedrooms. The CSCI has been informed that the system in place does not allow for this facility to be provided. Some of the bedrooms viewed reflected a range of individual styles and interests. All bedrooms have a call bell system linked to an alarm which is turned off at the main control panel rather than in the service users bedroom. Mount Denys Version 1.10 Page 16 There is one large communal area on the ground floor with further dining and lounge space on each of the units. One lounge is available for service users who wish to smoke. One bedroom has an en-suite facility, and there are sufficient toilets, and a selection of assisted bathing facilities in the home. Hot water was tested in eight wash hand basins and baths used by service users. One was recorded at 50.1 C in excess of the recommended safe temperature. This was reported to the Duty Officer for immediate resolution. Confirmation needs to be provided that the Water Supply Regulations 1999 are being met. There are policies and procedures in place, and the home was clean and free from offensive odours. Two domestic staff were spoken with who both spoke of procedures in place and of a good team working relationship. One relative also commented on the cleanliness of the home and the lack of odours. The recording of routine fire checks undertaken should be fully detailed and confirm the checks undertaken. The practice of wedging doors open fire doors should cease immediately in line with guidance from East Sussex Fire and Rescue Service. Mount Denys Version 1.10 Page 17 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, 28, 29 and 30. There is a stabile staff team in the home, which has lead to consistency in communication and the care provided. ESCC recruitment policies and procedures need to be followed in order to protect service users. There is detailed induction and foundation training in place to ensure that new staff receive the appropriate training to do their jobs. EVIDENCE: Staffing on the day was adequate to meet the personal care needs and staff spoken with and records viewed confirmed that this staffing level is maintained. All staff spoke very well of working in the home, of a good staff team working well together and of good communication systems in place. Relatives also confirmed that there appeared to be adequate staff on duty and of good communication. One member of staff was on duty to facilitate activities in the large downstairs lounge between 9.00 and 4.00. A trip out was available for service users but only four service users could participate in the ride due to the inability to provide further escorts for the journey. Mount Denys Version 1.10 Page 18 Staff training is ongoing and at the time of the inspection a number of staff were in the process of attending medication training. Two new staff confirmed that they were in the process of completing the required induction course and had and were due to attend a range of training opportunities. Both also confirmed that they received regular supervision. The Manager confirmed that care staff are working towards an NVQ qualifications in care to meet requirements. All recruitment is co-ordinated by the personnel section at ESCC’s head office, which the Inspector has visited and viewed sample documentation across the organisation’s registered services to support the recruitment process in place. Some gaps in the required documentation were found which need to be addressed. In future recruitment documentation will need to be available at the home as part of any inspection completed. The Manager confirmed that all staff now have a satisfactory Criminal Records Bureau (CRB) check in place. Mount Denys Version 1.10 Page 19 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 38 Service users and carers are enabled to give their views on the home and the care provided. ESCC quality assurance plan has not yet been fully implemented in the home. Satisfactory arrangements need to be put in place to ensure the health, safety and welfare and safety of service users and staff. EVIDENCE: The Manager of the home is an experienced senior manager. She is a State Enrolled Nurse, and holds the BTEC in Business Administration, Post Graduate Diplomas in Dementia Care, 941 English National Board qualifications, is a Manual Handling Risk Assessor, and an NVQ Assessor. The Manager also stated she has recently completed an NVQ Level 4 in Care. Mount Denys Version 1.10 Page 20 There are opportunities for service users and carers to put forward their views about the home and the care that they receive through service users meetings, and questionnaires which informs ESCC and staff in the home of the quality of the service being provided. This feedback has not yet been collated and available to view. Quality assurance plans are in place, but as yet have not been fully implemented in the home. Although Standard thirty-eight was not fully inspected, outstanding requirements were discussed and issues were raised during the inspection. The provision of fire training for all staff is still not in place. A relief member of staff had not received moving and handling training to meet requirements. A record of the maintenance of equipment and services is not in place. Mount Denys Version 1.10 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 1 x x x x x 2 2 STAFFING Standard No Score 27 3 28 x 29 2 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 2 x x x x 2 Mount Denys Version 1.10 Page 22 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. 2. Standard 9 19 Regulation 13 (2) 23 (4) (c)(v) Requirement That the recording of administration of medication is maintained. That a system is in place to ensure that the recording of the testing of fire equipment in the building also details the checks undertaken. That advice is sought on the current practice of wedging doors open and is acted upon. That hot water outlets accessed by service users is maintained at close to 43 C the recommended safe temperature. That the quality assurance annual plan for the home is in place, the results of service users surveys are made available to service users, and feedback is sought from other stakeholders. This issue is outstanding since 31.01.04, 28.02.04, 31.07.04, 31.01.05. That evidence is sent to the CSCI to confirm that a current electrical certificate is in place. This issue is outstanding since 31.12.04. That evidence is sent to the CSCI to confirm that a current gas Version 1.10 Timescale for action 26.04.05 30.06.05 3. 4. 19 25 23 (4) (a) 13 (4) (a) 26.04.05 26.04.05 5. 33 24 (1) (2) (3) 30.06.05 6. 38 4 (a) (c) 30.06.05 7. 38 4 (a) (c) 30.06.05 Mount Denys Page 23 certificate is in place. 8. 38 18 (c) (i) That it is ensured that all staff working in the home have undertaken moving and handling training to meet requirements. That suitable training in fire prevention is provided. The CSCI will receive confirmation of what is to be put in place. This issue is outstanding since 31.01.05 30.06.05 9. 38 23 (4) (d) 30.06.05 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 OP28 OP31 Good Practice Recommendations That a minimumof 50 of staff are trained to NVQ level 2 in care or its equivalent. That the Manager has a qualification at NVQ Level 4, in management and care or its equivalent. Mount Denys Version 1.10 Page 24 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Denys Version 1.10 Page 25 - 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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