Inspection on 21/06/06 for Mount Hermon

This inspection was carried out on 21st June 2006.

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 Hermon 23/01/06

Mount Hermon 29/07/05

Mount Hermon 03/02/05

Mount Hermon 08/07/04

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

CARE HOMES FOR OLDER PEOPLE Mount Hermon 85-87 Brighton Road Lancing West Sussex BN15 8RB Lead Inspector Mrs L Riddle Key Unannounced Inspection 21st June 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 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 Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mount Hermon Address 85-87 Brighton Road Lancing West Sussex BN15 8RB 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) 01903 752002 Mrs Wendy Rosemary Gray Mr Mark Andrew Gray Mrs Christine Turner Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number of places Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate up to two service users in the category Mental Disorder aged fifty-five years and over. 23rd January 2006 Date of last inspection Brief Description of the Service: Mount Hermon is a privately owned care home providing personal care for a total of twenty-six persons in the category Dementia over the age of sixty-five years. The registration makes provision for two persons who may be in the category of Mental Disorder, aged fifty-five years and over. The registered persons are Mrs. W. Gray and Mr. M. Gray and the registered manager is Mrs Christine Turner. The property is a large detached house situated on a main bus route on the seafront and five minutes walk from the town centre of Lancing. Parking is available to the front of the property. Resident’s accommodation is provided on the ground and first floors. A passenger lift allows access to the first floor. Two bedrooms on the first floor are not accessible via the lift and are only suitable for residents who are mobile and able to manage stairs. Accommodation is provided in twenty-four single and one double room. Nine rooms now have en-suite facilities. There is a garden to the rear of the property including a large patio area with seating and tables for residents’ use. The home’s fees range from £389 to £575 per week. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by one inspector which took place over one day between the hours of 9.30 am and 4.14 pm. Prior to the visit the inspector read previous inspection reports and reviewed various items of correspondence pertaining to the home. Information provided by the registered manager in a pre-inspection questionnaire also contributed to the inspection process. During the visit the inspector spoke with residents and staff, including the Registered Manager, undertook a tour of the home and examined a variety of records. Three visiting relatives were also spoken with. All requirements made following the previous inspection had been met within the given timescales. What the service does well: Mount Hermon provides a safe, clean, comfortable and cheerful environment for residents. Each resident is thoroughly assessed prior to admission to ensure that the home is a suitable placement for that person and can meet his/her needs. Staff are provided with appropriate training and have an understanding of resident’s individual needs. They are patient and sensitive in their approach. Residents can receive visitors at any time and visitors are always made welcome. Good wholesome home-cooked food is provided for residents and staff carry out close nutritional monitoring to ensure that each resident has a sufficient intake of food for his/her well-being. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Some risk assessments, especially those relating to tissue viability should include more information to show what action is needed in order to minimise the identified risk. More detailed information in care plans about known behaviours and what action staff should take when dealing with these, would assist staff and ensure more continuity of care for those residents concerned. Similarly, any signals, or non verbal communications which residents might be known to display in certain situations, should be recorded in their plans as this would assist staff to offer the appropriate assistance where residents may not be able to verbalise their needs. Duty rotas would benefit by showing the full names of staff as opposed to just Christian names. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 7 An effective quality assurance system, which includes an annual development plan and a means of monitoring the quality of care provided, has not yet been implemented. 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 Hermon DS0000014635.V289814.R01.S.doc Version 5.1 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 Hermon DS0000014635.V289814.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 A full assessment of needs is carried out before a resident is admitted to the home. The home does not provide intermediate care. The outcome for residents in relation to this standard is good. EVIDENCE: Only one admission had taken place since the last inspection. A full assessment of this person’s needs was seen to be on file and a care plan had been developed based on these assessed needs. The resident had been visited in hospital by the manager and provider prior to admission. The home has an admissions policy/procedure in place and this was examined. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Care plans are generally well set out and informative and the healthcare needs of residents addressed appropriately. Medicines are safely administered. Residents are treated with respect and their right to privacy upheld. The outcome for residents in relation to these standards is good. EVIDENCE: Care plans are in place for all residents. They are generally informative, based on assessed needs, and files include some personal history. Since the last inspection they now include details of checks and treatments and assessments of competences for staff undertaking any healthcare tasks. Some plans would benefit by more information being available to staff such as indicators for known behaviours. For example, signs a resident might display when he/she requires the toilet but cannot verbalise. Where certain behaviour is exhibited, there should be a clear procedure in the care plan for staff to follow in order to provide consistency of approach. For example, when one resident frequently puts herself on the floor and refuses to get up and another wanders into other people’s rooms. Risk assessments were seen to be in place in relation to known risks such as falls, moving/handling, going out, tissue viability. Tissue Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 11 viability assessments (Waterlow) do not however show the action needed to minimise risks where identified as high or very high. Files contain evidence of GP and other healthcare visits and appointments including community nurses. Resident weights are recorded monthly. Nutritional screening is carried out and appropriate action taken where a resident may not be eating a full diet eg. A supplement may then be given or medical advice sought. Staff keep written records of what each resident has eaten at each mealtime, which is good practice. Procedures for the administration of medication are in place and being followed. Medication administration record sheets were found to be all completed and up to date. Where medications are not given for any reason, this is now being recorded and the codes used. Staff have had training in the safe handling of medications. The medicine fridge temperatures are now being monitored and recorded as was seen. One resident said that she manages her own medication and keeps her room locked with her own key when she is not in there. A risk assessment was in place in relation to this person selfmedicating. Residents can remain in their rooms if they do not wish to socialise as was confirmed by a resident spoken with. He said he likes to remain in his room and enjoys watching out of his window because “there is always a lot going on” Capable residents have keys to their rooms and pass keys to the front door. Treatments and consultations are carried out in private. Consideration should be given to providing a more suitable place than the lounge for hairdressing to be carried out. The hairdryer was seen to take up quite a lot of space in the room, it also makes the room very warm and in general, the arrangement seemed to be far from ideal. Whilst for some residents it may be an enjoyable and social gathering, it could be a less than pleasant experience for others who may not wish to be observed by all when having their hair attended to. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The social, recreational and spiritual needs of residents are suitably addressed, they are able to have visitors at any time and maintain links with the community. Residents are offered good home-cooked meals, which are varied and balanced. The outcome for residents in relation to these standards is good. EVIDENCE: Care plans identify specific interests residents may have had and indicate what they like and are able to do. There is a programme of various recreational and social activities and the manager stated that this would be further developed on a more individual basis once the building works are finished and the vacancies filled. Fourteen residents were taken out in the afternoon of inspection to a strawberry tea at Lancing College. Staff said they take individual residents out for walks, to shops, seafront etc. Reminiscence sessions have been started and take place in a quiet room upstairs where various articles and pictures have been displayed to evoke memories and stimulate residents. This is done on a one to one or small group basis. A relative spoken with said that his relation had benefited greatly from this and made much progress since coming into the home. The activities programme also includes armchair exercises to video, music, simple games and manicures. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 13 A resident from an ethnic minority is able to maintain close links with her Community and actively follow her religion by attending Masses and meetings. This person also has regular and frequent social contact with others from that Community and is able to use her first language. Residents are encouraged and enabled to make choices as far as they are able in such matters for example as what they want to wear, what and where they want to eat, time of going to bed and getting up. One more able resident said “I like to get up late every day, I choose to have breakfast in my room and go to bed when I want”. Good home cooked meals are provided and alternatives always available as confirmed by able residents. Comments included ”food is very good, there is always an alternative if we don’t like something”. Special diets are catered for. Staff dice and offer fresh fruit to residents every day at teatime in addition to whatever else they are having. Menus show a good variety of meals offered over a four-week rotating period. Visitors are welcome at all times as confirmed by those spoken with whose comments included “It’s open visiting” and “I can visit whenever I like and I’m always made welcome and given refreshment”. Residents can receive visitors in the privacy of their rooms or in any of the communal areas including the quiet room on the first floor. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Any complaints would be taken seriously and acted upon by the management. Staff are aware of their responsibilities in relation to protecting the residents from all forms of abuse or bad practice. The outcome for residents in relation to these standards is good. EVIDENCE: The home continues to have an easy to understand procedure in place for complaints, which is included in the Statement of Purpose/Service User Guide and displayed in the home. Comments from residents and visitors indicated that there is confidence in the management to take any concerns and complaints seriously and deal with them as they arise. One resident said “if something is wrong I tell Chrissie (manager) or Wendy (provider) and they always put it right”. No complaints had been received as the manager confirmed. The home has a copy of the West Sussex Adult Protection procedures and policies and procedures for the home, which are consistent with these. Most staff have had training in Adult Protection and more will be doing this in September 06. Staff spoken with demonstrated an understanding of their responsibilities and recognised the vulnerability of those they are caring for. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Residents live in a safe, well-maintained and comfortable home that is suitable for purpose. The outcome for residents in relation to these standards is good. EVIDENCE: A tour of the complete premises was undertaken. Many areas and rooms have been upgraded and a programme of refurbishment is on going. Colour coding of certain areas has been carried out to identify toilets, stairs and communal areas for less able residents. Work to provide an extension with four additional en-suite bedrooms is still in progress and expected to be completed in the next two months. Work areas were all seen to be secured for resident safety and non-invasive. Many bedrooms have been upgraded and nine en-suite WC facilities installed. A number of rooms have had new furnishings provided and this will continue in rooms not yet done. All parts of the home were found to be clean and fresh. The laundry is suitably equipped. Infection control procedures are in place and staff spoken with were aware of these. Fire Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 16 precautions were being adhered to and it was seen that approved devices were fitted to all bedroom and other doors needing to be held open. Patio areas of the garden accessible to residents are pleasant with outdoor furniture provided. An unused bathroom on the first floor was seen to be still accessible and it was noted that some floorboards were missing making this very hazardous should any resident wander in. The manager undertook to have a bolt fitted to secure the door within twenty-four hours. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 Residents are cared for by sufficient numbers of staff who are able to meet their needs and who are appropriately experienced and trained to carry out the tasks they are required to perform. Recruitment procedures are sufficiently robust to afford protection to residents living in the home. The outcome for residents in relation to these standards is good. EVIDENCE: Four weeks duty rotas were provided to the Commission before the inspection and current rotas were examined at the time of inspection. These showed that staffing in the home is sufficient to meet the needs of current residents. The manager stated that levels would be increased when the extension is completed and further residents admitted. A staff-training programme is in place and staff have individual training profiles. Only two staff at present have National Vocational Qualifications (NVQ) at level 2 or above and therefore the home has not yet achieved the 2005 target for 50 of carers to be trained to level 2 or equivalent. On-going NVQ training is available and encouraged. Records of training undertaken and training arranged for the forthcoming months were seen. All staff have full formal induction as those spoken with confirmed, and training is provided in all health and safety topics. Records showed training had also taken place in a number of other work related topics such as Adult Protection, dementia awareness, night care of older people, safe handling of medicines and Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 18 challenging behaviour. Further training in these same topics was booked for the near future for staff who may not have undertaken them or who require updates. Staff were observed to take time to speak and engage with residents and this was particularly evident when one very deaf resident was becoming upset about something she perceived to be wrong due to her confusion. The staff took a great deal of time speaking to her clearly and loudly, but not shouting, trying to explain and reassure her that what she feared, was not so. Call bells were observed to be responded to promptly. One resident described the staff as “wonderful” and others including visitors made very positive comments about them. Four staff files were examined at random and found to contain all essential documents to show that robust recruitment checks are carried out including CRB/POVA checks and two references are obtained. The files would benefit by having recruitment checklists on the front covers as a reminder should any documents not have been received or need pursuing. The checklists were inside the files amongst other documents but had not been completed although the documents in the files examined were all found to be present. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33, 35, 38 The home is well managed and the health, safety and welfare of residents and staff is promoted and protected. The outcome for residents in relation to these standards is good. EVIDENCE: The registered manager is very committed to the all-round improvement of the service including the physical environment. The service history indicates that there has been a consistent quality of management and compliance with any requirements made. The manager has the Registered Managers Award, other management qualifications and a number of years experience in post. There is an open and inclusive style of management as was confirmed by staff spoken with. They said that constructive staff meetings are held, there is consultation and good communication and they found the manager to be supportive. Relatives spoken with also confirmed that the manager is always very Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 20 accessible and considered that she keeps them well informed of any significant events in relation to the progress or otherwise of their relatives in the home. There has been little progress as yet in relation to the implementation of a quality assurance/quality monitoring system and a requirement has been made in respect of this. Some questionnaires have been sent out to residents and relatives but results of these have not been analysed for use as quality assurance tools. The registered manager is aware of the work she needs to undertake in order to develop an effective quality assurance system and is committed to achieving this in the near future. Suitable arrangements are in place for the management of resident’s monies. Most residents due to incapacity have monies deposited by their representatives in the home’s safe keeping. Records and receipts for all expenditure are maintained. Three records were checked at random along with amounts of money held to ensure the balances were correct. All were found to be so. Training is provided in all health and safety topics as was seen in records and confirmed by staff spoken with. Policies and procedures relating to health and safety are in place. A risk assessment of the premises had been undertaken and individual assessments for residents were linked to care plans. Fire records showed regular testing of equipment and staff training is being carried out. Windows are fitted with restrictors and valves fitted to all hot water outlets to control hot water temperatures. All radiators are now covered including those in both lounges. Accidents are all recorded but the home should now be using a pro-forma, which takes into account DATA protection. Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 22 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 OP33 Regulation 24(1)(2)( 3) Requirement The registered person shall establish and maintain a system for reviewing at appropriate intervals a improving the quality of care provided at the care home. Timescale for action 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mount Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Hermon DS0000014635.V289814.R01.S.doc Version 5.1 Page 24 - 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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