Inspection on 08/12/05 for Mount Hall Nursing Home

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mount Hall Nursing Home 28/11/07

Mount Hall Nursing Home 05/10/06

Mount Hall Nursing Home 02/06/05

Mount Hall Nursing Home 18/11/04

Mount Hall Nursing Home 11/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Mount Hall Nursing Home Flash Lane Bollington Cross Macclesfield Cheshire SK10 5AQ Lead Inspector Helena Dennett Unannounced Inspection 8th December 2005 09:30 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 Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mount Hall Nursing Home Address Flash Lane Bollington Cross Macclesfield Cheshire SK10 5AQ 01625 574177 01625 560251 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) Goldsborough Limited Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home is registered for a maximum of 42 service users in the category of OP (old OP age not falling within any other category). The registered provider ust, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection.. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection. 2nd June 2005 3. Date of last inspection Brief Description of the Service: Mount Hall Nursing Home is a country house built in the 1830s. It stands in 6 acres of landscaped grounds in the rural village of Bollington and has been completely refurbished. There are surrounding gardens for residents use with a summerhouse, pond and greenhouse. The home was first registered as a nursing home in 1984 providing care for 34 residents. An extension was added to the existing premises in 1990 increasing the number of beds to 50. The number of service users accommodated was reduced in October 1997. The accommodation is provided on two floors and there is a passenger lift and staircases to both levels. The bedroom accommodation consists of 29 single rooms with 25 having en-suite facilities. There are 3 double rooms available all with en-suite facilities. There is a choice of lounge/dining areas including a spacious reception area, hairdressing salon and a laundry on site. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 8th December 2005, the inspector returned to the home on 20th December 2005 to complete the inspection, as the administrator for the home was not available. The inspector toured part of the building, looked at three residents files and other records, spoke with five residents and four members of staff including the administrator. Feedback was given to the temporary manager on 20th December 2005. What the service does well: What has improved since the last inspection? A programme of decoration and upgrading of the home is ongoing. Some bedrooms have been redecorated and fitted with new carpets since the last inspection. Staffing levels have been increased to ensure that residents needs can be met at all times. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Assessments of people’s care needs are carried out before they move into the home so there is information to show that their needs can be met at the home. EVIDENCE: There was evidence in the resident’s files that assessments of people’s needs are carried out before they move into the home so that staff are aware and can meet these needs. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 Residents are well cared for by staff in the home. However, some of the care plans do not contain sufficient detail on how to meet individual needs, so there is a risk that residents’ needs might not be met in full. EVIDENCE: Three residents files were examined. These contained details of assessment on admission to the home. The findings are not always put into the resident’s plan of care. Pre-printed care plans were in the files, however these did not always identify fully the needs of the residents. For example, one resident who was identified as requiring strong pain relief the weekend before the inspection did not have a plan of care addressing how that pain would be managed. The doctor had visited this resident and identified that he was suffering from increasing pain that required additional medication. In another residents file it was recorded under the evaluation of care that the resident required a specific hoist to assist her to move, this was not included in a care plan for mobility. Staff evaluate care given to residents every month and the findings are recorded very well, however the changes to the residents care should be then incorporated into the residents plan of care. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 10 Discussion took place with the temporary manager who agreed to address these issues. Four residents spoken with said that staff meet their needs very well. Comments such as ‘excellent staff, excellent care, staff act on concerns’ were made. Another resident said that ‘staff know my needs, help to control my pain and are excellent’. A doctor spoken with was positive about the care provided at the home. See Requirement 1 Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,&15. Residents can choose how they spend their time at the home, which enables them to keep control over their lives. There are no restrictions on visitors so residents can keep in touch with relatives and friends. Meals are well presented, varied and balanced providing adequate nutrition for residents to keep them healthy. EVIDENCE: Residents spoken with said that they can choose what they want to do during the day. One resident said ‘ I can suit myself, visitors come and go when they want to, there are plenty of activities and entertainers’. Most of the residents who spoke with the inspector said that the food was good and that they are offered a choice. One resident expressed concern that sometimes there is a delay in serving him his food, and that sometimes the morning cup of tea is not always as hot as he would like. However he said that when he tells staff they provide another cup of tea. The dining room was nicely set out for residents so that they can eat in pleasant surroundings. Visitors are welcomed into the home at any reasonable time. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Information about the complaints process is available so residents and their relatives know how to make complaints and who to make them to. Although there is an adult protection policy in place, some members of staff were not fully aware of the homes policy. EVIDENCE: All of the residents spoken with said they knew the complaints process and would complain to staff if they needed to. A policy on adult protection is in place, however one member of staff recently employed to work at the home was not fully conversant with the homes policy. She said she has not attended any training on adult protection. See Recommendation 1 Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 &26 A programme of decoration and upgrading of the home is ongoing. The standard of décor and furnishings is satisfactory, providing people living at the home with safe and comfortable surroundings. The home was clean and tidy providing a good standard of hygiene with no unpleasant smells EVIDENCE: The home is well maintained and provides a comfortable environment for residents to live in. Some bedrooms have been redecorated and fitted with new carpets since the last inspection. There is a sensory garden at the front of the building. This provides a very pleasant outdoor area that residents and their relatives will be able to use on mild pleasant days. The home was clean and tidy with no unpleasant smells. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 29 &30 There were plenty of staff on duty so that the needs of the residents could be met. Staff have attended a number of training courses so residents can be confident that they are in safe hands at all times and that staff are competent to do their job. All the necessary checks have been carried out on new staff before employment so residents are not placed at risk. EVIDENCE: A review of staffing levels has been done since the last inspection and additional staff have been provided to ensure that the needs of residents are met at all times. There were 27 residents in the building on the day of the inspection. There were two Registered Nurses and five carers on duty in the morning, two Registered General Nurses and four carers rostered for the afternoon/evening shift and one Registered Nurse and three carers for the night shift. The acting manager was not provided with any supernumerary hours when the inspector visited on 8th December 2005. However on returning to the home on the 20th December 2005 the temporary acting manager said that she was fully supernumerary. One qualified staff member said that she has been offered plenty of training, which she has found beneficial. Training records indicated that all staff are offered mandatory training, in addition training on care plan updates have Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 15 been held and training on the administration of sub-cutaneous fluids has been offered to the Registered Nurses. Staff new to post are provided with a comprehensive induction. All staff were seen to be professional in their approach. One staff member who had recently arrived from abroad knew the action to be taken in the event of an emergency. She was very positive about the staff and the support she has received since joining the company. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 35 Although there is no registered manager in the home at the moment, temporary arrangements are in place to ensure that there is no disruption to residents, relatives or staff and that the home continues to be managed in an effective way. There is a good system in place for the management of residents’ monies. EVIDENCE: The manager of the home has recently left her position. Arrangements have been made to interview potential applicants in the New Year with a view to appointing a new manager. In the interim period a temporary manager with experience as a deputy manager at a different home, has been asked to work at the home in a management capacity. She had joined the staff team a few days before the inspector returned to the home on 20th December 2005. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 17 Residents were very positive about the previous manager and deputy manager. They said they felt they were supportive and accessible and found residents meetings a positive experience. One resident said that she had been asked to fill in a satisfaction survey on the care and facilities provided at the home. She confirmed that she was told it could be anonymous if she so wished. The administrator was off duty on the 8th December 2005 and although there was a temporary administrator in, she was not fully conversant with the systems relating to the management of residents monies. Therefore arrangements were made for the inspector to come back on 20th December 2005 to look at resident’s monies and provide feedback on the outcome of the inspection. Resident’s monies are handled well. Residents’ monies are kept in one bank account, which is interest bearing. This is calculated on a monthly basis and credited to residents’ accounts. Receipts are kept for most transactions whenever practicable and two signatures are also recorded. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 x X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X X Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation 15 Requirement A care plan must be put in place as soon as practicable after a resident had moved into the home, which identifies the individual needs of the resident and how these needs are to be met. This must be revised after consultation with the resident and/or relative if the residents needs change. (timescale 15/7/05 not met.) Timescale for action 28/02/06 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 OP18 Good Practice Recommendations All staff should be offered training on adult protection. Mount Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Hall Nursing Home DS0000018773.V266958.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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