CARE HOME ADULTS 18-65
Mount Olive Residential Care Home 99 Shardlow Road Alvaston Derby Derbyshire DE24 0HJ Lead Inspector
Vanessa Davies Key Unannounced Inspection 26th February 2007 09:30 Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 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.V329334.R01.S.doc Version 5.2 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.V329334.R01.S.doc Version 5.2 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.V329334.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th October 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 South Eastern 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.V329334.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit and information for this report was gathered before and during the visit. Discussion was held with the Registered Provider/Manager, however all of the residents were out. The home’s records were examined, and the public areas and all of the bedrooms of the home were looked at. What the service does well:
The Registered Provider/Manager is very clear in her intention not to take any further Residents into her home. Following this inspection it was evident that the Registered Provider/Manager provided well for the three Residents within her care. 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. Residents attend a local church with the provider and her husband. Residents attend day centres during the week and the Registered Provider/Manager supports 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. The Provider stated that the health care needs of the residents were provided for. The Provider has purchased a full set of Policies and Procedures for the home since the last inspection. 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.V329334.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 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.V329334.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Lack of assessment information for residents potentially prevents their changing needs from being met. EVIDENCE: There was no evidence of an assessment of need for the residents living at the home, the provider was asked for this information and stated it was on a computer and would forward the information, this information had not been received. 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 intends to retire. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the Provider stated that she enables residents to make appropriate choices, lack of available written documentation prevented this from being evidenced. EVIDENCE: The Registered Provider/Manager had produced a very basic plan of care for one Resident and stated that all the other plans of care were on the computer and she was unable to access it, but would forward it to, this had not been received at the time of writing this report. l The inspector only met one resident for a few minutes prior to him leaving for a planned activity. The provider stated that residents were only able to make very limited choices about their way of life, and she supported them to make the choices. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 10 The Registered Provider/Manager said that residents were very aware of what they were able to do, and what was outside of their ability. 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. She did evidence appropriate policies and procedures to address this issue should it arise. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good, strong positive links with the local community enable residents to lead meaningful, positive lives. EVIDENCE: The Provider stated that the residents were very limited in their ability, but she worked hard to try to provide opportunities for them to develop social, and independent living skills. All residents went to church most Sundays and also attended midweek when the occasion arose. Outings with the church also take place, including holiday occasions at seaside resorts. Residents attend day centres most days of the week and treated the occasion as attending their place of work. The Registered Provider/Manager assists residents with benefits and financial problems as necessary. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 12 Residents take part in many activities arranged by the local churches. The Registered Provider/Manager provides transport, and this allows residents to take part in activities, as a small group, or as part of the larger church group. As well as attending church leisure activities, the Provider stated that the residents also take part in activities arranged for learning disability groups in Derby. The Registered Provider/Manager said that a number of these groups had become the hobbies and interests of the residents Two of the residents maintained links with their families. The Registered Provider/Manager encouraged this whenever possible, and the families can visit the home whenever they wished. The provider stated that she had worked hard to find a family member for one of the residents. The Registered Provider/Manager said that she would only enter residents bedrooms with their consent. One Resident has a key to the property and is able to come and go as he wishes. Residents have very personalised bedrooms and are able to spend time in their room or in the communal lounge, although the Provider and her husband share the same house they have their own lounge too. The Registered Provider/Manager provides 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.V329334.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the provider stated that personal and health needs are met, again lack of paperwork did not evidence this and therefore potentially resident’s needs may not be fully met. EVIDENCE: The Registered Provider/Manager provided personal support to all residents. Although there are no restrictions on bedtimes and getting up in the morning, residents are supported to get up in time for their transport to the day centre in the day. 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, however there were no records available to evidence this. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the best interests of the residents are considered at all times, allowing people to work at the home without a CRB completed by the home potentially puts the residents at risk. EVIDENCE: The Registered Provider told the Inspector that no complaints had been made during the past 12 months. A satisfactory Complaints procedure was seen to be in place. The Provider stated that she would address any complaint made accordingly. The Provider has a Safeguarding Adults procedure and keeps herself up to date with changes to the law, attending regular provider meetings. She does not currently employ any member of staff at the home therefore there were no staff records, however she did state that when she goes away with the church, the two female residents will be staying at the home cared for by friends of the church, these people have CRBs completed by the church but not the home. A CRB must be completed by the Provider for any person who will be working at the home paid or unpaid. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A well maintained environment, ensures that residents live in a safe home free from risks and hazards. EVIDENCE: The home provided good quality bedrooms and other space for all residents. A tour of the home showed that residents had personalised their bedrooms to varying degrees. The home appears to be safe and comfortable, and free from offensive odours. Due to the increasing disability needs of one of the resident’s, the Provider has installed a stair-lift. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from the Provider undertaking further training, particularly in record keeping. EVIDENCE: The Registered Provider obviously supported the main aims and purpose of the home and knows each resident very well. She is well aware of their skills, knowledge, abilities and limitations. She does not currently employ any staff therefore no staff records needed to be examined. As stated previously within this report all staff working with residents either paid or unpaid must receive a CRB completed by the Provider. The Registered Provider does not undertake regular training but stated that she keeps herself up to date by attending regular provider group meetings. She stated that she had attended Safeguarding Adults training and Fire training but no evidence of this was seen. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Unsatisfactory management systems for the Home, potentially prevents the service from developing and meeting the changing needs of the residents. EVIDENCE: The Registered Provide has managed the home from its initial opening many years ago. However, she still does not have an NVQ level 4 qualification in Management and refuses to undertake the qualification. She has completed training in Safeguarding Adults. Individual residents records need to be maintained and a quality monitoring tool should be developed to ensure that the service is reviewed and moves on with the changing needs of the residents. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 18 Insurance cover was in place for the Home and it’s operation. Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 19 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 Standard No Score 1 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 N/A 32 N/A 33 N/A 34 2 35 2 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 X X 2 X 1 X X 2 X Mount Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 20 Yes 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 YA10 Regulation 12 Requirement Timescale for action 30/04/07 2. YA31 18 3. YA35 18 4. YA42 23 Risk assessments must be provided and reviewed, 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 & 13/12/05) The Registered Provider/Manager 30/04/07 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 & 13/12/05) The Registered Provider/Manager 30/04/07 must arrange appropriate training for herself. (This issue should have been addressed from the inspection report dated 27 February 2004 & 13/12/05) Fire training must be provided 30/04/07 twice a year for the Registered Provider/Manager as she covers night duty. (This issue should have been addressed from the
DS0000001995.V329334.R01.S.doc Version 5.2 Mount Olive Residential Care Home Page 21 5. 6. 7. 8. YA2 YA18 YA23 YA39 14 15,17 7,9,19 Sch 2 24 inspection report dated 27 February 2004 & 13/12/05) All residents must have an up to date assessment of need in place. All residents must have a service user plan in place to address their needs. All persons working at the home, paid or unpaid must have a Criminal Records Bureau check. A quality monitoring tool must be developed and used. 30/04/07 30/04/07 30/04/07 30/06/07 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 Olive Residential Care Home DS0000001995.V329334.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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