Inspection on 23/01/06 for Mount Hermon

This inspection was carried out on 23rd January 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 21/06/06

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 Ms J Hartley Unannounced Inspection 23rd January 2006 11:30 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 Hermon DS0000014635.V274884.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.V274884.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.V274884.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. 29th July 2005 Date of last inspection Brief Description of the Service: Mount Hermon is a privately owned care home providing personal care for twenty six persons in the category Dementia over the age of sixty-five, and up to two persons in the category 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. C. 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. Service users accommodation is provided on the ground and first floor. 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 service users who are mobile. Accommodation is provided in twenty-four single rooms and one double room, some rooms provide en-suite facilities. There is a large garden to the rear of the property with a large patio area with seating and tables for service users. Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over a period of four and a half hours. The inspector examined information held on the service file since the last inspection in July 2005, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose During the inspection the inspector spoke to four of the service users, and two members of staff. Some of the home’s residents have communication difficulties due to the level of dementia experienced by them. Therefore, observation of daily routines and the quality of interaction between staff and residents was one of the main inspection methods used. The inspector undertook a tour of the premises and looked at four care plans and three staff files. Various record books, policies and procedures were also examined. The Pharmacist Inspector, Jeanette Datoo, was also present during part of the inspection. This report should be read in conjunction with the report of the announced inspection held on 29th July 2005. All the key standards, which should be inspected in a twelve-month period, are covered in these two reports. What the service does well: Mount Hermon has recently changed its inspection category from older people to older people with dementia. A lot of thought has gone into this change. The home has been made secure to prevent people from wandering into the busy road in front of the home. Internal area have also been provided with security keypads where there may be a danger to service users. The home is clean and comfortable throughout. Staff are patient and understanding with the residents, treating them with respect and dignity. Service users appear well cared for, and staff have an understanding of their needs. Thorough assessments are undertaken by the manager prior to admission to ensure that the home is able to meet the needs of prospective service users. Once living in the home, regular monthly reviews of individual care plans takes place. The residents enjoy the food provided. It is prepared using fresh produce. Visitors are made welcome in the home. Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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 Hermon DS0000014635.V274884.R01.S.doc Version 5.1 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 Hermon DS0000014635.V274884.R01.S.doc Version 5.1 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): 1, 3, 4 A new Service User Guide and Statement of Purpose are being produced to reflect the change in registration at Mount Hermon. Service users are assessed by the manager prior to moving into the home. Mount Hermon is able to meet the needs of the residents of the home. Mount Hermon does not provide intermediate care; therefore Standard Six is not applicable. EVIDENCE: On the day of the inspection the inspector saw a draft copy of the new Statement of Purpose and Service User Guide that are being produced to reflect the recent change in registration and recent changes to the home. The manager needs to send copies of these to the CSCI when they have been finalised. Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 9 Records seen during the inspection show that service users are only admitted after a full assessment has taken place either by the placing authority or the manager of the home. Mount Hermon has recently changed its registration category from old age to dementia. Training records show that some staff have received training in meeting the needs of older people with dementia. Training in this area should be made available to all care staff. Mount Hermon DS0000014635.V274884.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, 9, 10 Each service user has an individual care plan that is reviewed monthly. Areas of concern identified for medication handling need to be addressed. Service users are treated with respect by the staff at Mount Hermon. Their right to privacy is upheld. Standard Eight was inspected at the last inspection and was found to have been met. EVIDENCE: An inspection of service users’ files showed that each service user has an individual plan of care that sets out their health, personal and social care needs and goals. It was clear from the files that care plans are reviewed monthly. Medicines were stored in a lockable room with trolley and cupboards. A fridge was kept only for medicines but the temperature was not monitored. Records were kept of sample initials of staff who were authorised to administer medicines and their signatures to confirm that they had read and understood Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 11 the home’s medicines policy. Staff confirmed that medication training had been provided by an external organisation. For four medicines, there were omissions in the recording of administration, or the reason for non-administration. Separate records were kept of injections and the necessary blood monitoring. The system of faxing the blood results and receiving dose adjustments by telephone was explained to the inspector. Staff were witnessed performing care tasks whilst preserving privacy and dignity. The laundry system ensures that service users wear their own clothes. There is a cordless phone available for residents to receive telephone calls in private. There is also a pay phone situated in the library. The management team are in the process of adopting the Person Centred Practice approach for supporting people with dementia. Mount Hermon DS0000014635.V274884.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): 13, 14, 15 Service users are supported in maintaining contact with friends and relatives. As far as possible service users are able to exercise choice and control over their lives. Meals are wholesome and appealing and are served in pleasant surroundings. Standard Twelve was inspected during the last inspection and was found to have been met. EVIDENCE: Service users spoken to on the day of the inspection said that their friends and family are able to visit them whenever they like. They said that the staff team and manager make guests welcome. They are able to entertain their visitors in the privacy of their own rooms or in any of the communal areas. There is a small sitting room on the first floor that can be used by service users to entertain guests in private if they do not want to use their bedrooms. Staff were witnessed offering service users choices regarding where they wanted to sit to eat their meals. Service users are encouraged to bring personal possessions such as pictures, photographs and books with them when they move in. Furniture can be brought in with them if suitable, following discussion with the manager. Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 13 The meal that was served during the inspection appeared wholesome and was well presented. It was noted that fresh vegetables were used for the meal. Staff were witnessed assisting residents that required help, using patience and understanding. The mealtime was not rushed. Residents are able to choose to eat their meals in their rooms if they do not want to eat in the dining room. The dining room is a pleasant room looking out into garden. Mount Hermon DS0000014635.V274884.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 Mount Hermon has an easy to understand complaints procedure in place. Service users feel that their complaints would be listened to if they had any. The home has policies, procedures and training in place to protect service users from abuse. EVIDENCE: The complaints procedure was seen to be clearly set out in the Service Users’ Guide. The home has a book for recording any complaints they receive. There were no complaints recorded since the last inspection. Service users spoken to said that they feel that if they had a complaint it would be taken seriously by the manager and/or the owners of the home. Policies and procedures on adult protection were seen and found to be robust. The training record seen showed that most staff have received training in adult protection. The manager needs to ensure that all staff receive this training. The home has policies in place regarding dealing with verbal and physical aggression. Some staff have also received training on this subject. Mount Hermon DS0000014635.V274884.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, 24, 26 The location and layout of the home is suitable for its intended purpose. The home is clean, hygienic, safe and well maintained. Bedrooms are safe and comfortable. possessions in their rooms. Service users have their own Standard Twenty-Five was inspected during the last inspection and was found to have been met. EVIDENCE: Mount Hermon is situated on a main road with a parking area in front of the home. It is close to the sea and local amenities. Doors to the front of the home are made safe by the use of security keypads to protect people from wandering out into the busy road. The rear of the property has a secure, well laid out garden, which is accessible to all service users. A substantial programme of refurbishment is currently being carried out in the home. Bedrooms in the older part of the house are being redecorated and Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 16 refurnished. Bedrooms that are large enough are having en-suites added. The bedrooms that had been completed at the time of the inspection were seen to be of a very good standard. Corridors on the first floor are also being redecorated. It is planned that routes to places in the home such as toilets, communal areas and bedrooms will be colour coded to act as an aide memoir for people who are experiencing memory problems. All bedrooms seen were comfortable with good quality furniture and fittings. Bedrooms have locks and residents have keys. The locks are designed so that residents are able to lock the door when they leave their rooms, but staff have access when they are in their rooms in case of emergencies. Most radiators throughout the home have been covered, however there are two radiators, one in each downstairs lounge, that are uncovered. At the time of the inspection these radiators were very hot to the touch. The risk of burns was minimised by furniture being placed in front of them. The manager said that these would be covered soon. At the time of the inspection the home was found to be clean and free from offensive odours. Laundry facilities are sited away from food preparation and storage areas. Mount Hermon DS0000014635.V274884.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 The staff at Mount Hermon have, or are in the process of obtaining, the skills needed to support the service users in the home. At present the home does not have a minimum ratio of care staff with an NVQ Level Two or an equivalent qualification. Service users are protected by the thorough recruitment policies and procedures in place at Mount Hermon. Standard Thirty was inspected during the last inspection and was found to have been met. EVIDENCE: At the present time there are sufficient numbers of staff on duty to meet the needs of service users. One member of staff spoken to said that she felt there are not enough staff on at teatimes when there is no cook on duty. At this time staff have to prepare meals as well as care for service users. This was discussed with the manager of the home. Mount Hermon is planning to employ further domestic staff to enable the care staff to spend more time with residents at busy times in the day. The home employs two cooks and two cleaners. When the home is running at capacity after the refurbishments have been completed, the manager said that staffing levels will be reviewed as prospective service users are likely to higher and more complex needs than some of the current residents. Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 18 Some staff have already received training in dementia care and managing challenging behaviour. At present the home does not have a minimum ratio of care staff with an NVQ Level Two or an equivalent qualification. Five members of staff are currently enrolled on the course. The recruitment policies and procedures seen at this inspection were robust. Staff files inspected included all the required checks including; two written references, CRB checks and POVA checks. Mount Hermon DS0000014635.V274884.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, 36 The registered manger has the qualifications and experience needed to manage the home. The management seek feedback from service users and relatives to enable them to measure their success in meeting the aims, objectives and Statement of Purpose of the home. Service users financial interests are safeguarded by the policies an procedures of the home. The level of supervision of staff has improved since the last inspection. Standard Thirty-Eight was inspected during the last inspection and was found to have been met. Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 20 EVIDENCE: The registered manger has the skills, qualifications and experience to manage the home. Her qualifications include City and Guilds Advanced Management in Care and the Registered Mangers Award. She is also a qualified NVQ assessor. Evidence was seen that the home seeks feedback from relatives and service users regarding the quality of care provided. Due to the level of dementia experienced by some residents, there is only one resident who manages her own finances. Solicitors or relatives manage the finances of the other residents. The home has secure facilities available for the safe keeping of money and valuables on behalf of residents. Since the last inspection the frequency of staff supervision has increased. Of the records inspected it was noted that most staff had received five supervisions during the last year. The Standard requires care staff receive formal supervision at least six times per year. Mount Hermon DS0000014635.V274884.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 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 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 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X X Mount Hermon DS0000014635.V274884.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 OP1 Regulation 4, 5 Requirement The home needs to finalise the revised Statement of Purpose and Serice Users Guide and supply a copy to the Commission. Records of medicine administration must be accurate. When medicines, prescribed to be taken regularly, are not administered the reason should be recorded. Timescale for action 20/03/06 2. OP9 13 (2) 20/02/06 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. 2. Refer to Standard OP9OP7 OP9 Good Practice Recommendations Within the individual care plan there should be a record detailing the checks, treatment and responsibilities of all staff involved in doing delegated healthcare tasks. Assessment of competence of medicine administration should be recorded. For delegated healthcare tasks, there should be records of training and assessment, by the healthcare professional, of named care staff. DS0000014635.V274884.R01.S.doc Version 5.1 Page 23 Mount Hermon 3. 4. 5. OP9 OP36 OP28 The temperature of the medicines storage should be monitored to ensure that medicines are stored according to manufacturers instructions. Care staff should receive formal supervision at least six times a year. A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) was required by the end of 2005. Action should be taken to ensure that the home is meeting this Standard. Mount Hermon DS0000014635.V274884.R01.S.doc Version 5.1 Page 24 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.V274884.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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