Inspection on 09/03/07 for Mount Elton

This inspection was carried out on 9th March 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 Elton 25/02/09

Mount Elton 20/10/05

Mount Elton 03/05/05

Mount Elton 14/12/04

Mount Elton 20/05/04

Mount Elton 26/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Mount Elton 25 Highdale Road Clevedon North Somerset BS21 7LW Lead Inspector Barbara Ludlow Unannounced Inspection 9th and 19th March 2007 12:40 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 Elton DS0000020353.V316365.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 Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Elton Address 25 Highdale Road Clevedon North Somerset BS21 7LW 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) 01275 871121 01275 343245 mountelton@fsmail.net Churchill Property Services Limited Pauline Wakely Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 24 Patients aged 50 years and over, and 1 Nursing Patient in Bedroom 5 until vacated Staffing Notice dated 06/01/2000 applies Manager must be a RN on Parts 1 or 12 of the NMC register Date of last inspection 20th October 2005 Brief Description of the Service: Mount Elton is a converted Victorian house situated on the Clevedon hillside providing nursing care for up to 24 older people. The home is well maintained, comfortably furnished and has a homely atmosphere. Accommodation is provided in 12 single and 6 double rooms, arranged over 3 floors. Eight of the single rooms, and two of the shared rooms have en suite facilities. These are individually decorated in keeping with the character of the building. Many rooms enjoy panoramic views over the surrounding countryside. A passenger lift and built in ramps offer access to all areas of the home. The grounds are well maintained, and are used for a variety of social events over the year. The home has been suitably adapted for the current resident client group with handrails in corridors and grab rails in toilet facilities. The home has a nurse call bell system throughout. There is a Registered Nurse on duty at all times. An Activities co-ordinator is employed one day a week and provides a varied programme of creative activities for groups and individuals according to need. The fee range was stated as £525.00 up to £575.00. An increase of £28.99 was planned from1st April 2007 in line with the North Somerset Social Services increase. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspection visits was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. The inspection site visits were carried out over two dates. At the initial visit the manager was on holiday and the responsible individual nominated by the provider was not at the home. A mutually convenient appointment was made to ensure the manager would have an opportunity to participate in her first key standard inspection since becoming the registered manager. The first visit was made and the inspector met with the nurse in charge and was assisted with the start of the inspection process. The care staff on duty and the service users in their rooms were spoken with. A tour of the premises was made and care plans were sampled. The visit was well received and all staff were courteous and helpful. Staff spoke enthusiastically about the standard of care, the activities offered and their enjoyment working at the home. The atmosphere was relaxed and service users spoken with reflected this in their comments ‘happy here’, ‘can’t fault them’. The announced visit took place a week later and was more formally met by the homes management. The manager and the responsible individual gave their time and provided information throughout the inspection day to assist with the inspection process. All records requested were provided and it was pleasing to see that maintenance was up to date and records were securely and safely stored. Service users were seen in the communal areas of the home where constructive activities had been arranged by the care staff. Feedback was given to the Registered Manager. The inspector would like to thank all who participated in and who contributed to the inspection process. What the service does well: Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 6 Mount Elton is situated in a quiet area and has good views from the home. The building is attractive and home has pleasant communal rooms. Service users appreciate the homes situation and were pleased with their private accommodation. The grounds and large lawn area are level and are used in the warmer weather for activities and garden events. Staff spoke with pride about the social activities available to service users and the events held at the home each year. Efforts were being made to support a Mothers Day celebration. The home has a core team of staff who have worked at the home for some time. This brings continuity of care for the service users, which is appreciated, one person said ‘this is a good place’; ‘the staff work very hard’. A visitor commented that they are always welcomed and feel to be ‘part of the family’. The food received praise from service users, comment included ‘plenty of good food’, and ‘food is marvellous’. What has improved since the last inspection? What they could do better: The home has some new very tall sectional wardrobes, these are in two parts. The smaller top sections were not attached to the bottom sections. The whole units were not secured to the wall and were not stable; there is a potential risk of them falling forwards as a whole or in two parts and causing injury. This was brought to the attention of the Manager and prompt action was planned to attend to this. Confirmation is requested with the inspection response. Not all radiators, which are potentially hot surfaces, were covered to reduce the risk of burning should someone fall against one. This hazard should be included on the room risk assessments undertaken by the manager. Where a high risk is identified action should be taken. The homes recruitment processes were examined for eight new starters since the last inspection. With the exception of one reference all had two references in place. Criminal Record Bureau checks had been made but all were dated later than the start date of the employee. Unfortunately the responsible Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 7 individual had not retained the POVA First e-mails on file and it could not be confirmed that these had been received before the staff member had commenced working at the home. A record should be retained for all future recruitment practice where a staff member commences work under supervision before the full CRIB check is returned. The responsible individual assured the inspector that staffs POVA First checks were received before new staff commenced working at the home. One nurse registration renewal was not recorded on file. This was confirmed by the manager, using the Nursing and Midwifery Council on line service at the time of the inspection. One storeroom fire door was seen that was wedged open; this should be closed when the room is not in use. 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 Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 8 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 Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 9 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): 2,3,4 Quality in this outcome area is good. A pre admission assessment is undertaken to determine that care needs can be met at the home. Contracts were sampled and these demonstrated clearly the costs of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a brochure, statement of purpose and service user guide. Five care plans were sampled, evidence of pre admission assessment was recorded, and the admission sheet demonstrated that detailed information is gathered. One service user was asked about the admission process and said that the manager had visited them in hospital to make an assessment. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 10 The service user had been guided by their close family regarding choice of care home. The service user was very pleased with their choice and said they had settled in well. Information from hospitals following transfer to the home is used in care planning and is held on file. Assessment is made of skin integrity on admission or readmission from hospital and is reported to the nurse in charge for recording. This process was noted during the inspection and is good practice. Contracts were sampled, one for a publicly funded service user and one for a privately funded service user. The breakdown of costs of care was clearly stated. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10 Quality in this outcome area is good. Service users looked well cared for and confirmed this when asked. Care plans provided clear records of care needs and interventions. Wound care plans were excellent. Medications management with the exception of the oxygen storage was very good. Service users were heard to be treated respectfully and kindly. Service users asked reported that staff are ‘kind’. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans were sampled these included three people identified as having wound care for pressure ulcers. The care plans had photographic identification that was very nicely done and presented a very dignified and clearly identifiable picture of the service user. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 12 The care plan contained the pre admission assessment and detailed personal information was recorded. A shift handover sheet is held in each care plan that is completed by the key nurse. Comments are only made where there is something to report. Risk assessments had been completed; Waterlow scoring is used to determine the risk of pressure ulcer occurring and is rechecked on a monthly basis. Pressure relieving equipment was in use where stated and is used to prevent pressure ulcers developing. Body mapping is used to show the location of any skin problems and the date noted is recorded. Wound management charts are held separately and were excellent records of care management. The linking by cross referencing the care plan to an index in the wound care file was discussed with the senior nurse on day one of the inspection. Care plans sampled had been reviewed on 17/2/07. Information was present from visiting health care professionals such as the G.P and the continence advisor from the Primary Care Trust. Chiropodist visits were also recorded. Ill health prevention was documented, flu injections had been given. Service users looked well kempt and had been assisted with their jewellery and hairdressing; one person said they would choose what clothes and jewellery to wear each day. All interactions between staff and service users were heard to be kind, polite and respectful. The comments heard included that staff are ‘kind’, the manager was described as ‘nice’, and one of the nurses was spoken of fondly. Environmental risk assessments were included in the care planning these did not include the risk assessment in three areas. 1, Access to denture cleaning tablets in bedrooms. 2, Uncovered hot surfaces in bedrooms. 3, Tall two part wardrobes in bedrooms that are not secured together or to the wall and are unstable. See also Environment section, NMS 19 premises. Medications management was seen on day one. Medication Administration records were examined, there were two signatures on all hand transcribed entries and all medication administrations were recorded. Very good photographs were used for service user identification. Medications received are signed for on the confirmation delivery sheets. The medications fridge temperature is recorded daily; the range could also be recorded. Persons receiving anticoagulant therapy were closely managed and blood test results were recorded. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 13 Diabetic checks were recorded and equipment for capillary blood sugar monitoring was separate but was not sharp safe. The manager was asked to refer to the most recent guidance from the Medical Devices Agency ( under the MHRA )for advice about the use of lancets by staff in care homes. See NMS 26 Oxygen cylinders are stored on the ground floor, three were chained together to prevent them from toppling over, another five cylinders were freestanding but beneath a counter top. These should be made safe and be secured to prevent them toppling over and being damaged. Controlled drug management is used for Temazepam night sedation and was accurately accounted for. Skin creams obtained on prescription and seen in bedrooms were not labelled with an opened on or expiry date, this is recommended to ensure the efficacy and quality of the skin cream in use. Gel dispensers are available in the home for hand cleansing to reduce the risk of cross infection. On day two it was noted that a wheelchair was in use without footplates, the service users bare feet were seen skimming along just above the surface of the carpet. This practice poses a significant risk to the service user who could get a foot or both feet caught when being pushed along and could be injured. Good practice should not be compromised and footplates should be used at all times when moving a service user around the home. A requirement is made under NMS 22. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15 Quality in this outcome area is good. Service users are well cared for. The home has organised and varied activities each afternoon. The food is well presented and the menu is varied. Service users were satisfied with the service they receive at Mount Elton. Visitors are welcomed and those asked were satisfied with the care their relatives/ friends receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Twenty four service users were in residence on day one. The afternoon activity on day one was a film; The Sound of Music was shown on the large screen television in the main lounge, nine service users were watching the film together. Seven other service users were sitting in the quiet part of the lounge. On day two the service users had music and drawing, this was supervised by the care staff. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 15 The inspector heard from staff that they have parties and fund raising fetes/ events in the summer. These are held on the large lawn in the garden. The home has a notice board to advertise social events One member of the care staff team is allocated to assist with activities in the lounge each afternoon. On day one, service users were seen getting together to play scrabble, and one person was playing a board game with a member staff. The inspector heard that four social therapy sessions have been introduced, of these two are chair exercise sessions and two are craft sessions. Service users said they spent their time as they wished and have a choice in when they get up or go to bed. One spoke of their daily routine and of having their choice of hot malted drink at bedtime. Service users are able to personalise their bedrooms with photographs and ornaments and have their aids to daily living to maintain a level of independence. One communication aid was seen in use and a large buttoned phone was seen. One service user said they had help with their meals but sometimes could manage with a plate guard. One service user said they were very settled and happy at the home. Clothes were bought from the clothes show when needed or from the shops. The home has a named support worker and key nurse system giving service users and their families a links to staff. This system operates on a three monthly rotational basis. The cook and a kitchen assistant prepare the food each day. Tea and biscuits are served mid morning and mid afternoon. Cold drinks are available in the lounge at all times. Lunch on day one was fish and chips or cheese omelette and chips followed by treacle sponge and custard. The service user asked said it was ‘lovely’. Other service users asked said they enjoyed the food, there is ‘plenty of it’, ‘good meals here’ and ‘get a choice’. A kitchen assistant on duty at teatime and the food is served by the care staff. Supper drinks and snacks are also served by the care staff. The manager has introduced trays for meals served into service users rooms, this has improved serving practice. Mount Elton DS0000020353.V316365.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): 16,17,18 Quality in this outcome area is good. The home has a complaints policy. Complaints are investigated. Service users are protected from abuse by good care practices. The recruitment records held evidence of CRB checks for staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy. One complaint had been made in the past twelve months and this was unsubstantiated and dealt with within 28days. The service users are enabled to take part in the civil process and voting is supported. One service user confirmed that were ‘in touch’ and were on the electoral register. Service users are protected from abuse by good care practices and staff awareness. Service users spoken with were asked if they would raise any concerns and complain if unhappy about something. Positive and confident responses were heard about feeling able to raise any concerns with staff at the home. The recruitment records held evidence of CRB checks for staff but did not evidence the POVA First checks sent by e-mail being in place when the new staff member commenced working at the home. The responsible individual assured the inspector that staff POVA Fist checks were received before new staff commenced working at the home. See Staffing section NMS 29. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. The home has a warm ambient temperature and is clean, comfortable and homely. The communal spaces are well used and the level garden is used in warmer weather. The home has been suitably adapted and refurbishment is ongoing. Some environmental health and safety issues are raised in this section. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made. The home is on three floors, referred by staff as three distinct areas, the ‘nursing wing’, the ‘Red landing’ and the ‘ground floor’. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 18 Bedrooms were clean, comfortable and had been made homely by the individual service users adding personal items such as ornaments, pictures and photographs. Corridors have handrails to support service users who are independently mobile. The home has aids and adaptations such as assisted bathing and toilet facilities, hoists and wheelchairs. On day two it was noted that a wheelchair was in use without footplates, the manager stated that this had occurred because the four person passenger lift cannot accommodate the wheelchair with the footplates on. Good practice should not be compromised and footplates should be used at all times when moving a service user around the home. A requirement is made for good practice. The new shower facility is well used; six bars of soap had been left behind after use. There is no hand washbasin in the shower room. The assisted bathroom (Room 22) was seen the hot water maximum temperature recorded here was only 35 degrees Celsius and may need adjusting up slightly. Five bars of soap were seen in this bathroom. Bars of soap pose a risk of cross infection if shared and care should be taken to return them with the service user after bathing or taking a shower to eliminate this risk. Staff took action to rectify this at the time of the visit. Service users were satisfied with their accommodation and appreciated the location and the outlook. The dining room has been swapped with the conservatory and this appeared to be working well and has created a well-used second lounge area. Environmental risk assessments had been included in the individuals care planning. These did not include the risk assessment of unprotected potentially hot surfaces which can pose a risk to service users who may burn themselves if should they fall against one and be in direct contact with the hot surface. Unsecured tall wardrobes, which were unstable, were not included in the risk assessment, they pose a risk of toppling forwards and causing an injury. These risk assessments must be made and action taken where a risk to a service user is identified. The sluice facility has a disposal facility and a sluice disinfection cycle machine but does not have a separate hand-washing basin. Staff have access to a toilet facility on the red landing. Gel dispensers are situated around the home for hand cleansing, this encourages good infection control practice. Diabetic checks were recorded and equipment for capillary blood sugar monitoring was separate but was not sharp safe. The manager was asked to Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 19 refer to the most recent guidance from the Medical Devices Agency (under the MHRA) for advice about the use of lancets by staff in care homes. See NMS 26 The manager said here there was no policy and procedure for the use, the cleaning and the storage of the suction machine seen in bedroom ready for use. It is advisable to have clear practice guidance for this equipment, which could pose a risk of infection to the service user if not cleaned appropriately. The laundry has two washing machines and two tumble dryers and has dedicated staffing Monday to Saturday each week. Where pumped chemicals are used eye protection should be available for the staff to use to reduce the risk of accidental splash injury to the eye with chemicals that bear COSHH hazard markings, a recommendation is made under NMS 38 The kitchen is well equipped and looked to be very kept clean and tidy. The home has a cleaner on duty each day and the level of cleaning around the home was very good. The home has a handyperson to undertake maintenance work at the home. The home has a fire alarm system, detection equipment and fire extinguishers that are all maintained. A laundry fire occurred last year, prompt action by the staff on duty, who were praised for their well drilled response minimised the effects. The home has a storage facility used for incontinence pads situated at the top of a small flight of stairs. This storage space has been extended and has a designated fire door. This fire door was seen to be left wedged open, this door should be closed when the room is unattended. Mount Elton DS0000020353.V316365.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): 27,28,29,30 Quality in this outcome area is good The home has a skill mixed staff team with a registered nurse at all times. There was sufficient staff on duty to meet the needs of service users. Staff receive induction and training. Recruitment records should include evidence of PoVA First checking. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On day one of the inspection six staff were on duty, three were trained nurses and three were care assistants. From the change of shift at 2 pm four staff were on duty of these two were trained nurses. The night shift is from 8pm until 8am and there were due to be two staff on duty overnight. The home has introduced a twilight shift to provide support between 8pm and 11pm however this cover is not provided every day but usually for five days each week. Eight staff files for new starters since the last inspection were sampled. All had a Criminal Record Bureau (CRB) check but all were dated later than the start date of the employee. The responsible individual had not retained the POVA Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 21 First e-mails on file and it could not be confirmed that these had been received before the staff members had commenced working at the home. A record of the POVA First check should be retained with all future recruitment practice where a staff member commences work under supervision before the full CRB check is returned. The responsible individual assured the inspector that staff POVA Fist checks were received before new staff commenced working at the home. With the exception of one reference all new starters had two references on file. All new staff receive an induction pack, which contains a fire and manual handling policies. Staff are trained in fire safety by the responsible individual. Staff were spoken with and all spoke positively about working at the home. Staff meetings are held every six to eight weeks, the minutes are printed and staff that were unable to attend can sign to say they have read them. Training and development is supported, four staff have attended a course at the hospice. Key working has been introduced and the manager felt this was having a positive impact on care and on staff responsibilities. All observed interactions between staff and service users were kind and thoughtful. Service users commented that the staff are ‘kind’ and ‘helpful’. Mount Elton DS0000020353.V316365.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): 31,32,33,35,38 Quality in this outcome area is good. The home is well managed and there is management and administrative support from the company Responsible Individual. Management systems are in place to safeguard and protect service users from harm. Views and feedback are sought to monitor the quality of the service. Routine maintenance is well organised and is recorded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well managed and the company responsible individual is based at the home and is involved in the day to day management of the home. There is also administrative support. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 23 The manager to improve the clinical record keeping such as the care records has implemented changes. Records were seen to be stored securely and access was appropriately restricted. The Responsible Individual acts an as an appointee for two service users whose details were declared on the pre inspection information. Charges for extras such as hairdressing, newspapers, toiletries or chiropody are invoiced to the service users. Servicing records were inspected, these included fire alarm records and testing, these were all up to date. In house monthly checks on the emergency lighting was done up to 6/03/07. Fire drill training is carried out on a weekly basis when the alarm is tested. The list in the foyer of service users in residence was dated 14.08.06 and may need updating. One fire door was seen wedged open this is reported under NMS19. Bedroom risk assessments for hot surfaces and unstable wardrobes are required under NMS 19. New style accident reports are completed and are reviewed by the manager prior to them being stored. All hoists, bath hoists and person weigh scales had been serviced. The lift had been serviced in December 2006 and had just had a call for repairs. The gas servicing was carried out in November and December 2006. Portable Electrical Appliance testing was last done in February 2006 and was due. Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 3 3 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 08/05/07 arrangements for: Oxygen cylinders that were freestanding must be stored in a secure and safe manner to prevent accident or injury occurring. 08/05/07 The registered person shall ensure that: 1.Denture cleaning tablets were seen in bedrooms, these are dangerous if ingested. Their accessibility and storage must be risk assessed for the individual service user. 2.There are potentially hot surfaces in bedrooms that are not covered and pose a risk to service users who may burn themselves if they should fall against one or be in direct contact with the hot surface. These exposed surfaces must be risk assessed for the individual service user accommodated in that bedroom. Requirement 2 OP19 13(4) (a) and (c) Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 26 3 OP22 23(2)(c) 3. Unsecured tall wardrobes that are unstable and could topple forward and cause an accident were seen in some bedrooms. These must be risk assessed and action taken as necessary. The registered person shall ensure that: Wheelchairs must be used safely with the footplates in position for the safety and comfort of the service users being transported. 08/05/07 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 OP19 Good Practice Recommendations The designated fire door on the pad storeroom should be closed when room is not being used. Advice could be taken from the fire service regarding any changes to the fire precautionary measures for this room. Where pumped chemicals are used in the laundry eye protection should be available for the staff to use to reduce the risk of accidental splash injury to the eye with chemicals that bear COSHH hazard warnings. The latest guidance for staff in care homes from the MHRA website for use of lancets by staff should be accessed and action should be taken to ensure best practice at all times. The suction should have cleaning guidance and storage information for it’s safe use, to reduce the risk of cross infection. 2 OP38 3 4 OP26 OP26 Mount Elton DS0000020353.V316365.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Elton DS0000020353.V316365.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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