Inspection on 29/07/05 for Mount Hermon

This inspection was carried out on 29th July 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 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 23/01/06

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 Jo Hartley Unannounced 29 July 2005, 11:00 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 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 H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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 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 (CRH) 26 Category(ies) of Old age, not falling within any other category registration, with number (OP), (26) of places Physical disability (PD), (26) Physical disability over 65 yers of age (PD(E)), (26) Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home can accommodate up to two (2) service users in the PD category within the total number of twenty-six (26) service users. 2 Only service users in the category (PD) over the age of 60 years may be admitted. Date of last inspection 3 February 2005 Brief Description of the Service: Mount Hermon is a privately owned care home providing personal care for twenty six persons over the age of sixty-five years and two persons aged between sixty years and sixty-five years. 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, five rooms providing 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. The registered persons have recently applied for a variation to their registration to accommodate older people with dementia. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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 two and a half hours. The inspector read information held on the service file since the last inspection in February 2005, and read the previous two inspection reports. During the inspection the inspector spoke to seven service users, and two members of staff. The inspector undertook a tour of the premises and looked at six care plans and four staff files. Various record books, policies and procedures were also examined. What the service does well: 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 H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 7 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 standard(s) 3, 4 Service users have their needs assessed prior to moving into the home. Mount Hermon does not provide intermediate care; therefore Standard six does not apply to this service. EVIDENCE: Six service user files were inspected and all held evidence of a pre-admission assessment being completed prior to admission. The information gathered in the assessments had been used to inform the individual care plans. Training records seen on the day of the inspection show that the home is able to meet the needs of individual service users. Apart from Health and Safety training, some staff has also received training in Parkinson’s disease, diabetes, promotion of continence, and the safe handling of medicines. The home has recently applied for a variation to their registration to accommodate older people with dementia. Four staff have received training in dementia care, and two in managing challenging behaviour. The Service User Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 8 Guide and Statement of Purpose will need to be updated to reflect the proposed changes in the home. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Care plans include individual health, personal and social care needs. Service users’ health needs are fully met. Service users are able to self-medicate where appropriate. The home has policies, procedures and risk assessments regarding medication and self-medicating. Service users feel that they are treated with respect by the staff and that their right to privacy is upheld. EVIDENCE: Six care plans were inspected on the day of the inspection. They all held care plans generated from a comprehensive assessment of needs. Care plans include goals of individual service users and what action needs to be taken to meet them. Evidence was seen that care plans are reviewed regularly, most on a monthly basis, although in some cases there were six weeks between reviews. Health care needs of service users are met by the home using community health services. One service user said that the home had assisted and supported her in attending appointments to have cataracts removed. Care plans include risk assessments for falls and pressure sores. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 10 Adequate policies, procedures and records were seen for the receipt, recording, storage, handling, administration and disposal of medicines. Following an assessment, service users are able to self-medicate where appropriate. The home has an agreement in place that is signed by service users who choose to self-medicate. Service users said that the staff treat them with dignity and respect their privacy. Staff was witnessed knocking on service users’ doors before entering their rooms. Service users said that they are able to receive visitors in the privacy of their own rooms. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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 standard(s) 12 Service users find that the lifestyle in the home matches their expectations and meets their needs. EVIDENCE: Service users spoken to said they are able to choose whether or not they take part in activities organised by the home. They also said that they could choose where they eat their meals and what time they get up in the mornings and go to bed at night. One service user said, “The place is geared to you, you are always being told it’s your home, you can have all your own things in your room. You are not restricted in any way unless it is a risk to yourself.” Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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 standard(s) 18 The home has policies, procedures and training in place to protect service users from abuse. EVIDENCE: It was noted that a copy of the West Sussex Multi Agency Guidelines on the Protection of Vulnerable Adult is retained in the home for reference purposes. Comprehensive Adult Protection and Whistle Blowing policies including guidance for staff were seen during the inspection. Since the last inspection the home has provided training for staff in Adult Protection. Both members of staff spoken to during the inspection had an awareness of Adult Protection procedures to be followed if they suspect abuse. All the staff files seen at the inspection had current Criminal Records Bureau checks. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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 standard(s) 19, 24, 25, 26 Service users live in a safe, clean, comfortable environment with their own possessions around them. Some maintenance and redecoration is needed in certain parts of the home. EVIDENCE: The location and layout of the home is suitable for the service user group accommodated, with local amenities within a short distance of the home. Communal lounges are homely and comfortable but some areas, particularly the upstairs corridors, are in need of repair and redecoration. The proprietors are planning extensive redecoration, including the use of “colour coded” areas to aid recognition for service users with dementia. The home has recently employed a maintenance man. Most bedrooms were in good decorative order, comfortable, and had service users’ own possessions in them. One service users’ bedroom was found to have wallpaper peeling from the walls, however the service user has asked for her room not to be redecorated, as she does not want the disruption. This is clearly recorded and signed by the service user in her care plan. Bedroom Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 14 doors have been fitted with locks. Rooms are centrally heated, have adequate lighting and ventilation and radiator covers have now been fitted. Since the last inspection fire doors have been fitted with automatic closing devices. On the day of the inspection the home was found to be clean, hygienic and free from offensive odours. Laundry facilities are suitably sited away from areas of food preparation and storage. Policies and procedures were seen regarding infection control. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The numbers and skill mix of staff meets service users’ needs. The homes recruitment policies and procedures support and protect service users. Staff receive training and support to enable them to be competent to do their jobs. EVIDENCE: Rotas seen during the inspection showed that an adequate number of staff is on duty to meet the needs of the current service users. Both members of staff interviewed said that staffing levels have improved recently, although one felt that there are occasions when there is not enough staff on duty, particularly during times of staff sickness. There are two waking and one sleeping night staff on duty during the night. Policies, procedures and staff records seen on the day of the inspection indicate that the home has a thorough recruitment procedure. Two written references are obtained, and Criminal Records Bureau and Protection of Vulnerable Adults register checks are made prior to staff starting work at the home. New staff receives a statement of terms and conditions of employment. Records were seen, and staff spoken to confirm, that new staff are now receiving induction training. Staff training provided by the home has improved and includes Adult Protection, Health and Safety and courses specific to the needs of the current service users. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 38 Staff receives formal supervision from management, although not always on a regular basis. The health, safety and welfare of service users and staff are protected. EVIDENCE: Both members of staff spoken to said that they receive formal supervision and appraisals. Records seen indicated that supervision is being undertaken but can be erratic in frequency. Staff should receive supervision at least six times a year. Both members of staff highlighted that they find the management team very supportive both professionally and personally. Staff receives training in Moving and Handling, Fire Safety, First Aid, Food Hygiene and Infection control. Evidence was seen that fire extinguishers had been checked in July 2005. Policies and procedures were seen regarding COSHH, Health and Safety, First Aid, Infection Control and Food Safety. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 17 Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 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 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x 2 x 3 Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? 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 1 Regulation 4, 5 Requirement The home needs to prepare a revised Statement of Purpose and Serice Users Guide to incorporate proposed changes. Timescale for action 29/10/05 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 36 19 Good Practice Recommendations Care staff should receive formal supervision at least six times a year. Redecoration is needed in some areas of the home. Mount Hermon H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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 H60-H11 S14635 Mount Hermon V233488 290705 Stage 4.doc Version 1.30 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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