Inspection on 26/11/07 for Mount Denys

This inspection was carried out on 26th November 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mount Denys 30/05/06

Mount Denys 10/11/05

Mount Denys 26/04/05

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 2AE Lead Inspector Judy Gossedge Unannounced Inspection 26th November 2007 11:45 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 Denys DS0000041274.V352644.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. Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Denys Address 187 The Ridge Hastings East Sussex TN34 2AE 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) 01424 421353 01424 421925 flobeddall@eastsussex.gov.uk www.eastsussex.gov.uk/socialcare East Sussex County Council Mrs Florence Gertrude Beddall Care Home 31 Category(ies) of Dementia - over 65 years of age (31) registration, with number of places Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The maximum number of service users to be accommodated is thirtyone (31). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. Five (5) places will be available for service users between the age of fifty-five (55) and sixty-four (64). One (1) named service user who has been assessed as requiring nursing care be accommodated. One (1) named service user with mental health issues can be accommodated. 30th May 2006 Date of last inspection Brief Description of the Service: Mount Denys is a purpose built property on two floors, situated on the outskirts of Hastings and approximately two miles from the town centre. Managed by East Sussex County Council (ESCC) it is a specialist service for older people living 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 within three units in the home. There are two units of ten beds and one unit of eleven beds, which are used to provide service users with accommodation for either long term care, short stay, respite care and periods of assessment. There is only one en-suite facility, but there are sufficient toilet and assisted bathing facilities on each of the units. Each unit has a dining and lounge area for service users to use. Additionally there is a large lounge area on the ground floor. Level access is facilitated in the home with the provision of a passenger lift. A pleasant garden is at the rear of the home. Fees charged are in accordance with ESCC policy and procedures and at the time of the inspection the charges are £98.60-£523.02. The level of fees charged will depend on the outcome of a financial assessment. Additional charges are made for hairdressing, newspapers and toiletries. The Statement of Purpose, Service Users Guide and a copy of the last Inspection report are available to read in the reception area of the home. Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Inspection took place over six hours on 26 November 2007. Prior to the Inspection an Annual Quality Assurance Assessment (AQAA) was sent to the home, which has been completed but was returned late after a further request for the information had been made. The information detailed within is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms and care records were inspected. Thirty service users were resident and a number were spoken to as part of the Inspection process. The care that four of the service users received was reviewed. The opportunity was also taken to observe the interaction between staff and service users in the communal areas. Six service user surveys were sent out and three came back completed either with or by relatives. Seven care workers; the cook, a kitchen assistant, an administrative assistant and the Acting Manager were all spoken with. Five relatives/visitors surveys were sent out and four came back completed. A General Practitioner (GP) and a visiting Social Worker each completed one of these surveys. One relative was also spoken with over the telephone. What the service does well: What has improved since the last inspection? Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 6 The recording of administration of medication has been maintained. Staff has received fire training. A system to enable a fall risk assessment to be completed on admission has been put in place. Further work has been undertaken to improve the environment in the bedrooms and bathrooms. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mount Denys DS0000041274.V352644.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 Mount Denys DS0000041274.V352644.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential new service users are individually assessed prior to any admission to ensure that their care needs can be met in the home and there is information about the home for service users and their representatives to reference. EVIDENCE: The Statement of Purpose and Service Users Guide are available to read at the entrance to the home with a copy of the last Inspection report. Both documents need to be updated to reflect recent changes to staffing and the care provided on each unit and to ensure all the required information is detailed within. This was discussed with the Acting Manager who stated this would be addressed. The three service user surveys stated that they had had adequate information about the home and one commented, ‘I was happy for my relative to go to Mount Denys as I had had good reports of the home.’ Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 9 Prior to admission to the home service users have an assessment completed, primarily by staff from the Community Mental Health Team, or staff from one of ESCC Adult Social Care Department’s Assessment Teams. A copy of the assessment is then forwarded to the home. For two new service users at Mount Denys, the pre-admission information had been received. Staff confirmed that they also visit a new service user prior to a planned admission to gain information to help them provide the required care. Where service users are being provided with regular respite care the assessment had been subject to regular review. Where service users are admitted between reviews staff stated verbal confirmation of the current situation is sought prior to the service user being admitted for the next period of respite care. Again this was discussed with the Acting Manager, as this needs to be evidenced and recorded for staff to reference. New care workers receive an induction and attend mandatory training. There are policies and procedures in place for staff to reference. There is a programme for National Vocational Training (NVQ). Intermediate care is not provided in the home. Mount Denys DS0000041274.V352644.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have individual plans of care, but it should be ensured that all the service users care needs are identified on admission. Personal care and support is provided in a way that maintains and respects the privacy, dignity and lifestyle of the service user. There are detailed policies and procedures in place to manage medicine to be followed to ensure the protection of service users. EVIDENCE: The AQAA detailed that there are policies in place to ensure that equality and diversity issues for individual service users are both identified and incorporated into service users individual plans of care. Eight of the service users individual care plans were viewed. The recording and seven care plans were very detailed and gave clear guidance to staff of the care to be provided, service users health care requirements, dietary needs, social and leisure interests. Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 11 Supporting risk assessments were also viewed and where there are any identified risks the recording detailed how these will be managed. For one new service user who had been admitted on the 19 November did not have a care plan drawn up and there was no supporting risk assessment in place. This was discussed with the Acting Manager who stated this should be completed on admission and that this would be rectified with immediate effect. It was evidenced that staff were in the process of working on these documents to review care plans and risk assessments. But not all had had a monthly check to ensure the care plans were still up-to-date. Two service users surveys stated that they always received the support they needed and one usually. Two stated staff always acts and listen on what you say and one did not know. All service users are registered with a local General Practitioner (GP) and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, that appointments with or visits by health care professionals are recorded. Two service users surveys stated they always received the medical support they needed and one usually. Feedback from the visiting healthcare professional was that they were satisfied with the overall care provided, that the home worked in partnership with them and commented, ‘ excellent care home. Medication policies and procedures are in place. The storage and a sample of the recording of the administration of medication were viewed. Staff spoken with had received medication training, although some were due for an update to meet the organisations policy and procedures. All the service user surveys completed indicated that service users felt that their medical care needs were always or usually met in the home. The care provided was observed being delivered in a way to ensure service users dignity and respect was maintained. The feedback received from the service user surveys and relatives was that they were pleased with the overall care provided in the home. Comments included, ‘I am very pleased with the care my relative is receiving at Mount Denys. The staff are always cheerful and dedicated’, ‘we were very grateful to the home for the good care and support they gave us; we would use the home again. The staff were very kind and caring’ ‘I feel my relative is happy at Mount Denys and that is all thanks to the staff including cleaners, workmen etc.’ and staff are exceptionally good, terribly flexible, good natured and fun to be with, ‘ ‘the home always strives to provide a well rounded holistic service,’ and ‘I do not think my relative could be anywhere better.’ Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 12 Mount Denys DS0000041274.V352644.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible service users are enabled to exercise choice in their lives whist resident in the home, there are opportunities to participate in social and recreational activities, but it should be ensured that all service users are able participate if they wish, service users are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: The AQAA detailed that some staff have attended training to provide meaningful activities and that there are a variety of activities on offer including chair-based activities and there is a monthly church service. A sample of the recording of activities arranged was viewed, which detailed the newspaper being read, jigsaws being completed, skittles and sing a longs and dancing. Staff stated there are now more opportunities for service user’s to go out on trips if they wish and how much service users enjoyed these outings, and of plans in place to go and see the Christmas lights. It was acknowledged in the AQAA that this is an area, which it is planned to be continuing to be developed over the next year with a wider range of activities being provided and more Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 14 external entertainment being arranged. Service users have social interests recorded on their individual care plans. On the day of the Inspection the weather was cold and only one of service users took the opportunity to wander in the garden area. Staff stated limited activities were arranged during the morning due to repair works being carried out on one of the units, which had lead to breakfast and lunch being served in the large lounge. But staff went through the day’s newspaper with service users. Activities were organised in the downstairs lounge during the afternoon with some service users joining in a reminiscence session all about Hastings and one service user was being helped with their Christmas cards. It was observed that there was a good atmosphere and interaction between staff and service users. No activities were arranged on the day for service users on the respite care unit. With observations on the day, staff spoken with and service users and relatives comments evidenced that activities are being organised for some of the service users to participate in. Two service users surveys stated there were always activities arranged in the home and one usually. One commented, ‘my relative is encouraged to do lots of things.’ Another stated that their relative would not be able to join in the activities, but enjoys the space in the home to wander around, which they like to do. The care and support provided was observed to enable service users where possible to exercise choice whilst at Mount Denys. The seven service user files viewed, observations on the day and the relative’s feedback confirmed this. The AQAA details that service users are encouraged to maintain contact with family and friends. Two relatives were visiting during the Inspection. One relative spoken with confirmed that there is very flexible visiting, that they are always welcomed and can visit with their relative in private if they wish. The cook and kitchen assistant working in the kitchen on the day were spoken with and stated they both hold a basic food hygiene certificate. There is a four-week rotating menu in place. A choice is not recorded at all meals, but staff spoke of alternatives kept on the units that can be provided, and service users were seen to be choosing their meal from the choice available at lunchtime on the day. Frozen meals are used to provide the main meal at lunchtime in the home, although the Acting Manager stated that more fresh cooked meals are now being introduced onto the menu. The AQAA detailed this is an area which is to be improved over the next twelve months. Special diets are catered for. Lunch was liver and bacon or vegetable lasagne with mixed vegetable and boiled potatoes, followed by tinned peaches and custard. A sample of recording to evidence a varied and adequate diet for all service users from the records kept of food consumed individually by each service user. Service users were observed eating their lunch on one of the flats and in the large lounge. There was a relaxed atmosphere during the meal. Fresh fruit is available on the units. Two service users surveys stated they always liked the food provided and one usually. One commented, ‘my relative loves her Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 15 food,’ and another stated that the staff are very good at listening to relatives views and following this had adjusted their relatives meals to meet their individual requirements. Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. 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. The AQAA detailed that one complaint had been received since the last nspection relating to the homes environment. Two service users surveys stated they always knew who to speak to if they were unhappy and one usually. One commented, ‘I do not know if my relative knows who to speak to she usually tells any member of staff. But the staff are quick to pick up on anyone who is not happy.’ There are detailed policies and procedures in place in relation to the protection of vulnerable adults and a whistle blowing policy. All but one the care workers spoken with had an awareness of adult protection procedures and stated they had received training/update. It was not possible to evidence the training/guidance provided to all staff, as there were no records of when staff had undertaken this training. This was discussed with the Acting Manager who Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 17 stated that the organisation provided training/update but that it was not always easy to get all the staff who needed an up-date a place on to the training. The CSCI was notified of one concern, which was investigated under safeguarding adult’s procedures, following which the concern was not substantiated. Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standard of the environment continues to be improved to ensure that service users with an attractive and homely place to live. EVIDENCE: A tour of the building was made. The AQAA detailed that in the last twelve months further work has been completed to refurbish the large downstairs lounge, all corridor areas have been redecorated, new carpeting fitted and the main kitchen has been refurbished. There are thirty-one single bedrooms. Service users are unable to control the temperature in their own bedrooms. The CSCI has been previously been informed that the heating system in the home does not allow for this facility to Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 19 be provided. Several of the bedrooms were seen and 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. The CSCI had been informed at the last Inspection a new emergency call system was due to be fitted in the home, but this has not occurred. Only one bedroom has en-suite facilities, but there are adequate toilets and assisted bathing facilities on each of the units in the home. It was apparent that work had been undertaken to try to make the bathrooms more homely. There were records of regular checks of the hot water temperature carried out in the home to ensure outlets accessed by service users are close to the recommended safe temperature of 43° C. There is a dining and lounge space on each of the flats. There is also a large lounge on the ground floor. There is a very pleasant garden at the rear of the home, which has been subject to major work to improve this facility. Staff spoke of this facility being very popular in the warmer weather. The home was clean and free from offensive odours. The three service users surveys stated the home was kept fresh and clean. One commented ‘ I have never noticed a smell and it always looks nice.’ None of the housekeeping staff were spoken with on this occasion, but the AQAA detailed that staff had received training/guidance in infection control and the control of substances hazardous to health regulations (COSHH) It was evidenced in the home that there was good access to protective clothing. Recordings of the regular fire checks carried out in the home were viewed. Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels need to be kept under review to ensure all service users care needs are met. A robust recruitment procedure needs to be demonstrated to be in place to ensure service users are in safe hands at all times. EVIDENCE: A copy of the staff rota was viewed for the week. On the day of the Inspection there were six care workers on duty during the morning and six in the afternoon with a Senior Care Officer on duty. One care worker was also working 9.0-3.0 to facilitate activities in the large lounge. The Acting Manager was on duty during the day. Discussions with staff and records viewed confirmed that staffing levels have been maintained. Recruitment to care worker posts has lessened the reliance on agency and relief staff to work in the home. Ancillary staff were also on duty covering domestic, catering, maintenance and administrative tasks. As a number of the service users are only resident for short periods of care there is a high number of admissions and discharges. Staff on the respite care unit spoke of being very busy due to the number of admissions and discharges and there were no activities provided Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 21 during the day on this unit. The AQAA detailed that staffing levels is kept under review and this was discussed with the Acting Manager as the dependency and care needs of individual service users continually changes and to ensure service users the social care needs of the all the service users resident are met. Two of the service users surveys stated they felt that they always received the care and support that they needed and one usually, that staff listened and acted upon what was said to them and two stated that staff were always available when they were needed and one usually. One commented, ‘there is always a member of staff for my relative to talk to and when we visit and I can telephone and talk to someone any time day or night,’ ‘I have always found staff at Mount Denys to be helpful and knowledgeable,’ ‘well informed and knowledgeable staff,’ and ‘the carers are great and do not get all the recognition they deserve.’ The AQAA detailed eighteen of the thirty-four of the homes care staff hold an NVQ level 2 in care and one further care staff are currently working towards this qualification. Also that three of the homes agency, pool, or bank staff also hold this qualification. All recruitment of ESCC staff is co-ordinated by the Personnel Section at ESCC’s head office. Evidence of the recruitment process followed for new staff is held at the home. Four staff files were viewed did not evidence the recruitment process followed as detailed in the AQAA. Only two had evidence of an application form being completed, one did not have photographic evidence in place, one did not have evidence of two written references and one only had one written reference in place. Criminal Records Bureau (CRB) checks for staff have previously been evidenced and the Acting Manager was able to confirm the four new staff had a CRB check in place. The AQAA details that ESCC has a induction training programme in place, which meets the Skills for Care requirements and new care staff are expected to complete. Two new care wokers spoken with confirmed they had received an induction and on three of the staff files viewed there was documentary evidence of an induction having been completed. The organisation has a yearly appraisal process in place for staff. Mount Denys DS0000041274.V352644.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The overall management of the home is good with effective systems to protect service users being put in place, but these need to be maintained. EVIDENCE: The Registered Manager for the home has just moved to another position within the organisation and a senior care officer who has worked in the home for many years is currently seconded as Acting Manager whilst permanent managements are put in place. There are clear lines of line management and accountability within the organisation. Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 23 ESCC has a quality assurance plan and 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 forums and a sample of the minutes of these meetings were viewed. Service users/representatives are also asked to complete a questionnaire at the end of a period of care. Feedback from the quality assurance process undertaken at Mount Denys for 2006/7 was available to view at the time of the Inspection. This details how the service is monitored and feedback from consultations with service users. The feedback stated of the fifty-nine questionnaires returned during the last year, ninety-eight, percent of the service users stated they were very satisfied/satisfied with the service and two percent stated they were dissatisfied. The AQAA detailed that policies and procedures were in place, but did not detail when these had been reviewed and the AQAA should be fully completed. Quality assurance visits by a representative of ESCC are completed and recorded to meet the requirement under Regulation 26. The records of the last two visits were viewed and the Acting Manager confirmed that recommendations following these visits had been addressed. Where money is held in safe keeping for some service users a sample of the financial records to support this activity was viewed and was adequate. Staff spoken with and records viewed confirmed that staff supervision and team meetings occur regularly. Staff stated they had attended a range of training and training updates. They all spoke of good access to training opportunities for personal development of Staff training records had been completed and were available to view, so it was possible to evidence that all staff had received the required moving and handling, basic food hygiene and fire training. Staff confirmed they were due to attend infection control training. But records did not detail alls staff had received first aid training and the Acting Manager stated that there could be difficulty in accessing this training for all staff as required. Accident records were viewed and were collated, so that any trends in incidents or accidents occurring in the home can be highlighted. A fire risk assessment was viewed but had not have been updated since April 2006. This was discussed with the Acting Manager who stated this would be addressed, so a Requirement has not been made on this occasion. The AQAA detailed that a check of the environment and fire precautions had been carried out to meet the timescales as detailed in ESCC’s policies and procedures. But recording viewed evidenced this had not taken place. This was discussed with the Acting Manager who stated this would be completed with immediate effect. Staff spoken with and records viewed evidenced that staff had undertaken fire training. The organisation has a system in place to evidence that the maintenance of equipment and services has been carried out. Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 24 Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 25 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 (1) (a) (b) 13 (4) (a) Requirement That a thorough recruitment a process is demonstrated to be in place, to protect service users. That regular checks of the environment and fire precautions are maintained to meet the organisations required timescales and protect service users and staff. That systems in place ensure staff have received the required updates in POVA and first aid. Timescale for action 31/12/07 2. OP38 31/12/07 3. OP38 23 (4) (d) 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mount Denys DS0000041274.V352644.R01.S.doc Version 5.2 Page 28 - 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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