CARE HOME ADULTS 18-65
Mount Olive Residential Care Home 99 Shardlow Road Alvaston Derby Derbyshire DE24 0HJ Lead Inspector
Steve Smith Unannounced Inspection 18th October 2005 03:40 Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 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 Olive Residential Care Home DS0000001995.V251007.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 Adults 18-65. 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 Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Mount Olive Residential Care Home Address 99 Shardlow Road Alvaston Derby Derbyshire DE24 0HJ 01332 571470 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) Mrs Gloria Emphemia Holness Mrs Gloria Emphemia Holness Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26 August 2005 Brief Description of the Service: Mount Olive Care Home is part of the ‘home’ of the Registered Provider. It provides care for up to three Residents, and is situated on the southeastern corner of Derby, in the area known as Alvaston. Each Resident has their own bedroom, although all three share the sitting room and dining room, which is often also used by the Registered Provider. The Home has a large garden available to Residents. Within the limitations of each Resident they are encouraged to take part in the general running of the Home. Mount Olive Residential Care Home DS0000001995.V251007.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 in just under 1hour. Discussion was held with the Registered Provider/Manager. Some of the Home’s records were looked at, and the public areas and all of the bedrooms of the Home were examined. What the service does well:
The Registered Provider/Manager was very clear in her intention not to take any further Residents into her home. Residents will either live out their lives at the Home or will eventually be asked to leave, due to the retirement of the Registered Provider/Manager. From this inspection it was evident that the Registered Provider/Manager provided well for the three Residents within her care. Social Services Dept Care Managers reviewed each Resident at yearly intervals. Residents’ ability to make choices was supported and one Resident was encouraged to make financial decisions, although only in a very limited way. The Registered Provider/Manager had a procedure to follow in the event of a Resident going missing from the Home, although fortunately this had so far never been needed. Not only were Residents supported well within the Home, but they were also well supported by the local churches. Apparently, they were very welcoming and frequently took them, with the Registered Provider/Manager, on trips away from the Home. Residents attended day centres during the week and the Registered Provider/Manager supported them by resolving any financial issues. Other evening activities involved learning disability groups in Derby, and the Registered Provider/Manager regularly planned holidays for the Residents. The families of Residents could visit them whenever they wished. Residents’ days in the Home were balanced between the business of weekdays and attending day centres, and the weekends when they could be more relaxed. Good health care was provided for all Residents, two of whom assisted with this by managing some of their own medication. The Home had a satisfactory Complaints procedure, and Protection procedure. The Home was maintained to a good standard throughout, and insurance cover was provided for the Home and its operation. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 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 Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. The Registered Provider/Manager does not intend to take any further Residents into the Home. EVIDENCE: The Registered Provider/Manager explained that she had no intention of taking any further Residents into her Home. Either, the current Residents will leave in the due course of time, or the Registered Provider/Manager will require the Residents to leave to enable her to retire. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,9 and 10. The Registered Provider enables Residents to take appropriate risks, given their abilities. However, risk assessments had not been updated since each Resident first moved to the Home, therefore it was unclear whether Residents abilities had improved or deteriorated. EVIDENCE: The Registered Provider/Manager had produced a very basic plan of care for each Resident. However, due to their severe difficulties it had not been appropriate to share their plan of care with them, although Social Services Dept. Care Managers had reviewed the care provided at annual intervals. Residents were only able to make very limited choices about their way of life, although the Registered Provider/Manager supported them to do so. One Resident was able to manage finances in a very limited way, and the Registered Provider/Manager supported this. The Registered Provider/Manager said that Residents were very aware of what they were able to do, and what was outside of their ability. She provided
Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 10 limited risk assessments, completed close to the start of each Resident’s stay in the Home, but they had never been updated. This requirement was listed in the inspection report of February 2004. The Registered Provider/Manager said that she would respond promptly on any occasion a Resident was absent from the Home without an adequate reason. However, to date this had never happened. The Registered Provider/Manager had provided a written procedure to follow should such an event occur in the Home. The inspection report of February 2004 suggested to the Registered Provider/Manager that she provide a policy on ‘Confidentiality’. At the time of this inspection she had not done this. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 15, 16 & 17. Links with the local community were good and supported and enriched Residents social and educational opportunities. EVIDENCE: The Residents were very limited in their ability, but the Registered Provider/Manager attempted to provide opportunities for them to develop social, and independent living skills. Residents went to church most Sundays and also attended midweek when the occasion arose. Outings with the church also took place, including holiday occasions at seaside resorts. Residents attended day centres most days of the week and treated the occasion as attending their place of work. The Registered Provider/Manager assisted Residents with benefits and financial problems as necessary. The Registered Provider/Manager regularly supported Residents in the evenings and weekends as part of her duties. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 12 Two of the Residents maintained links with their families. The Registered Provider/Manager encouraged this whenever possible, and the families could visit the Home whenever they wished. The Registered Provider/Manager provided a wide range of meals, which she said were enjoyed by all of the Residents. Mealtimes were described as being relaxed, unrushed, and flexible to suit Residents activities. Residents generally attended day centres, but when appropriate, meals were served three times a day, and at least one of these was always cooked. Drinks and snacks were also available at all other times of the day. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20. Residents’ personal needs were well met, ensuring that their privacy, dignity and independence were maintained. The system of administering medication was good, and arrangements were in place to ensure Residents medication needs were met. EVIDENCE: The Registered Provider/Manager provided personal support to all Residents. This included the male Resident who had previously indicated that he was happy to be supported by her to maintain his personal hygiene. During the week, Residents had to be up in time to meet the bus that took them to their Day Care placements, although at weekends they could get up when they wished. The Registered Provider/Manager said that times of going to bed were flexible, and happened around 9.30 pm to 10.30 pm. All of the Residents required some guidance concerning personal hygiene. The Registered Provider/Manager said that Residents’ health was regularly monitored and potential complications and problems were identified and dealt with at an early stage. Residents were also offered minimum annual health checks. GPs and District Nurses always saw Residents in private. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 14 Records were kept of all medicines received, administered and leaving the Home, to ensure that there was no mishandling. The Registered Provider/Manager administered almost all medication, although two Residents were encouraged to administer some of their medication. The Registered Provider/Manager monitored the condition of each Resident and would call in the GP if she became concerned about their health. No Resident was taking a Controlled Drug. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. A system was in place to record all complaints and the protection policies and procedures provided by the Home meant that Service Users were protected. EVIDENCE: The Registered Provider/Manager told the Inspector that no complaints had been made during the past 12 months. However, the Residents ability would prevent them from making a complaint. Relatives, who could act on one Resident’s behalf, if ever a complaint was to be made, supported that Resident on a regular basis. A satisfactory Complaints procedure was seen to be in place. The Registered Provider/Manager explained and showed the Home’s new Protection procedure. However, the Registered Provider/Manager still did not have a Whistle Blowing procedure for her or any part-time staff to follow. Similarly, the Registered Provider/Manager was unaware of the Public Interest Disclosure Act of 1998 or of the Dept of Health guidance ‘No Secrets’. These issues have been outstanding since February 2004. However, she did say that all allegations and incidents of abuse would be followed up with the assistance of the local Social Services Dept. The Registered Provider/Manager safeguards Service Users money, which she holds, and she was aware of the prohibition from assisting in the creating or benefiting from Service Users wills, but this was not documented. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30. The Home was very well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: The Home provided good quality bedrooms and other space for all Residents. An examination of the Home showed that Residents had personalised their bedrooms to varying degrees. The Home was found to be safe and comfortable, and free from offensive odours. The Home was also found to have sufficient light, and was well heated and ventilated. Due to the increasing disability needs of one of the Resident’s, the Registered Provider/Manager was in the process of arranging for a stairlift to be installed in the Home. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 &35. Support to Residents would be enhanced by the Registered Provider/Manager undertaking appropriate training to meet the need of Residents. EVIDENCE: The Registered Provider/Manager obviously supported the main aims and purpose of the Home and knew each Resident very well. She was very aware of their skills, knowledge, abilities and limitations, and invited in specialist advisers if at all necessary. However, she was not aware of the standards of conduct and practice set by the General Social Care Council, and had not obtained the General Social Care Council’s code of practice. This was included in the announced inspection report of February 2004, and so needs to be urgently addressed. The Registered Provider/Manager did not undertake regular training. In the main this was due to ‘training companies’ unwillingness to attend to the needs of so small a home. However, the Registered Provider/Manager was advised to team up with other small homes and try again to arrange training. This had apparently been done for Fire issues, but not as yet for general training needs. This same issue was listed in the announced inspection report of February 2004, and still needs to be urgently addressed. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 40, 41, 42 & 43. Satisfactory management systems for the Home were established, thus Residents benefited from a well run and managed establishment. EVIDENCE: The Registered Provider/Manager had managed this Home from its initial opening many years in the past. However, she still did not have an NVQ level 4 qualification in Management. The Home’s budget was appropriately managed and certificates and licences were obtained and displayed. During this last year the Registered Provider/Manager has undertaken training in Whistle Blowing, Adult Protection and Moving and Handling. The Registered Provider/Manager needed to review the policies and procedures listed within Appendix 3 of the National Minimum Standards, and to ensure that she complied with them all. The Registered Provider/Manager also needed to ensure that she had sight of and understands all the policies and procedures
Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 19 that applied to her home. This issue was listed in the announced inspection report of February 2004, but has not as yet been addressed. Individual records and Home records were securely maintained, and were in order. Although Residents could be given access to their individual records, their ability does not allow for this, and the Registered Provider/Manager was therefore supported in her decision not to offer this to Residents. The Registered Provider/Manager would be undertaking Fire training later this year. However to date it had not been provided. This issue had been listed in the inspection report dated February 2004. Insurance cover was in place for the Home and its operation. Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 2 X X X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Mount Olive Residential Care Home Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 2 3 2 3 DS0000001995.V251007.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement The Registered Provider/Manager must carry our risk assessments, on at least an annual basis, on each Resident ensuring that these are acted upon and recorded in each Resident’s plan of care. (This issue should have been addressed from the inspection report dated 27 February 2004) The Registered Provider/Manager must provide a policy that states that no one in the Home can benefit from or assist Residents in the making of their wills. (This issue should have been addressed from the inspection report dated 27 February 2004) The Registered Provider/Manager must become familiar with and comply with standards of conduct and practice set by the General Social Care Council. (This issue should have been addressed from the inspection report dated 27 February 2004) The Registered Provider/Manager must arrange appropriate
DS0000001995.V251007.R01.S.doc Timescale for action 1 YA10 12 13/12/05 2 YA23 20 13/12/05 3 YA31 18 13/12/05 4 YA35 18 13/12/05 Mount Olive Residential Care Home Version 5.0 Page 22 5 YA37 9 6 YA42 23 training for herself. (This issue should have been addressed from the inspection report dated 27 February 2004) The Registered Provider/Manager must obtain an NVQ in Management no later than December 2007. Fire training must be provided twice a year for the Registered Provider/Manager as she covers night duty. (This issue should have been addressed from the inspection report dated 27 February 2004) 31/12/07 13/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard YA10 Good Practice Recommendations The Registered Provider/Manager should provide a policy on ‘Confidentiality’. (This issue should have been addressed from the inspection report dated 27 February 2004) The Registered Provider/Manager should provide a ‘whistle blowing’ policy for the Home. She should also obtain copies of and understand the Public Interest Disclosure Act 1998 and the Dept of Health guidance ‘No Secrets’. (These issues should have been addressed from the inspection report dated 27 February 2004) The Registered Provider/Manager needs to review all policies and procedures listed in Appendix 3 of the Care Homes Regulations, and ensure that the Home complies with them. She also needs to ensure that she understands those policies and procedures that are relevant to the daily tasks. (This issue should have been addressed from the inspection report dated 27 February 2004) 1 2 YA23 3 YA40 Mount Olive Residential Care Home DS0000001995.V251007.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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