CARE HOMES FOR OLDER PEOPLE
Mount Pleasant Pentalek Road Camborne Cornwall TR14 7RQ Lead Inspector
Lynda Kirtland Announced Inspection 2nd May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mount Pleasant DS0000009165.V338007.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 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 Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Mount Pleasant Address Pentalek Road Camborne Cornwall TR14 7RQ 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) 01209 716424 Mr Alan Herbert Blight Mrs Deborah Jane Blight Mrs Jacqueline Ann Dart Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th September 2006 Brief Description of the Service: Mount Pleasant provides care for 19 older people. The home is situated near to the centre of Camborne. The registered providers are Mr and Mrs Blight. The registered manager is Mrs J Dart. The property offers spacious accommodation for service users. Shared rooms include two lounges and a dining room. The majority of bedrooms are en suite and there are no shared bedrooms. Bedrooms are located over three floors, with a stair lift allowing access to the upper levels of the home. There are sufficient bathroom facilities on each floor. There is a pleasant garden, which includes a summerhouse. The ground floor of the home and the garden are accessible to wheel chair users. The home also offers a day care service. A copy of the inspection report is available on request. The fee at the time of the inspection range from £300.85 to £410 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An announced key inspection occurred on the 2 May 2007 and lasted for approximately seven hours. Information about the home received by the Commission since the previous inspection was taken into account when planning the inspection. The purpose of the inspection was to ensure that residents’ needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. This involved interviews with residents (service users) living in the home and observation of the daily life and care provided. There was an inspection of the home’s premises and of written documents concerning the care and protection of residents and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the home’s registered manager. An update as to how the management team are progressing towards compliance with the requirements identified at the previous inspection was gained. One method used was case tracking, of which three service users were selected. This involves examining the care notes and documents for a select number of residents and following this through with interviews with them and staff working with them. This provides a useful, in-depth insight as to how residents’ needs are being met in the home. The inspector would like to thank residents, staff and the registered manager for their cooperation and assistance during this inspection. What the service does well:
Residents were complimentary about the care that they receive at Mount Pleasant. Some comments included ‘ the staff are lovely’, ‘staff are patient’, ‘ there is no grumbles here’ and ‘they can’t do any thing to improve the care here, its excellent’. Residents felt that a competent staff team met all their care needs in a sensitive manner. Residents recently admitted to the home commented on how the staff made this a positive experience and they felt that the welcome to the home was friendly. Residents said that they have good access to healthcare services and the home actively promotes good health by encouraging them to attend keep fit sessions, monitoring diet and acting promptly to any health issues. Residents said that activities are provided for them in accordance with their expectations and preferences and they are able to choose whether or not to
Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 6 join in. There was a calm, pleasant and restful atmosphere in the home and residents felt their visitors were welcomed to the home. Residents stated that the food is ‘excellent’ and that there is a choice of main meal. Records of food are kept and demonstrated a nutritious diet. Special occasions are celebrated with one resident commenting that Christmas was ‘fit for the Queen’. The dining area is in pleasant surroundings and it was observed that the main meal was an unrushed and social occasion. Although residents were not sure about the formal procedures for making complaints, they said that they would feel confident about taking any concerns they have to the home’s manager. All residents said they were satisfied with the care and services provided to them and that they had not felt the need to make formal complaints about the home. Residents confirmed that they also attend ‘residents meetings’ where they can discuss any issues and also participate in the planning of future events in the home. The registered manager has a quality assurance system where she gains residents, their representatives and professionals view as to the service that Mount Pleasant provides. All views expressed were positive about the care, accommodation and staffing skills provided at the home. The registered manager agreed to complete a summary of the responses she has received and forward this plus an action plan to the Commission. The home was comfortable, attractively furnished and decorated throughout. The registered manager stated that there are planned ongoing improvements to upgrade and maintain the building so that residents benefit from a homely environment. Residents said that there is sufficient staff to meet their needs. In addition to care staff, there are domestic, catering, and management staffs so that care staff have sufficient time to work directly with residents and spend time with them. The registered manager ensures that relevant health and safety checks , such as fire equipment are maintained and regularly checked. What has improved since the last inspection?
Since the previous inspection the registered manager has complied with all the statutory requirements and majority of recommendations. They are as follows: It was evident from discussion with residents and documentation that the registered manager ensures that a full assessment of care needs is carried out prior to admission at Mount Pleasant. Information regarding the facilities and services that the home provides is given to all residents. The storage, administration and disposal of medication is satisfactory and was audited by the pharmacist in April 2007 which did not highlight any concerns.
Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 7 The medication policy needs to include the homes practice on the use of oxygen. Separate records are now kept regarding all medical interventions for individual residents e.g. chiropodist, dentist etc The home was clean and hygienic throughout. Staff were aware of the risks of infection control and COSH and have received recent training in this area. Policies in respect of the use of protective clothing have been reviewed. A risk assessment, and evidence of consultation has been undertaken regarding if residents have a particular restriction i.e. use of en suite. A review of staffing levels has taken place in particular around teatime. Documentation demonstrated that the registered manager has undertaken observations of this time of day, has discussed the issues with residents individually and at their meeting and with staff. All residents felt that staffing around this time was satisfactory and commented that their care needs are ‘always met quickly’. Some staff are still not satisfied with the levels of staffing at this time and the registered manager agreed to continue to monitor this. The registered manager believes that staff morale has increased. All checks needed by regulations are completed when recruiting new staff. Staff confirmed along with training records that there has been a increase in training at the home. Examples of recent training are infection control, , food hygiene, and NVQ level 2. Currently 13 out of 16 care staff have a NVQ level 2 or above. Recent electric hardwire and updating fire systems have been completed. What they could do better:
Residents have a satisfactory care plan which identifies their individual and diverse care needs. It is recommended that further expansion is needed so that for those residents with more complex needs they inform, guide and direct staff as to what interventions are needed and care can be provided in a consistent manner. It is also recommended that risk assessments be expanded so that staff are aware for example of what equipment is needed if a resident experiences a fall. The registered manager should make a minor amendment to the adult protection policy and staff should attend the Multi Disciplinary training. It is acknowledged this is a oversubscribed course and the manager is to congratulated on undertaking a adult protection course in house in the interim period. Some issues in respect of the environment need to be addressed: Lighting in the kitchen and medical cupboard must be covered as currently the light fitting is exposed, if it breaks this would create a health and safety hazard: The carpet on the top floor of the home and in room 15 is not laying flat leaving ridges, which could cause a tripping hazard: Three bedrooms are identified as
Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 8 fire exits, risk assessments of the individuals that use these rooms in particular around accessing the fire escape stairs must be undertaken due to potential health and safety risks: Paper towelling must be providing in toilet areas to promote infection control: The bathroom carpet (top floor) must be replaced to promote infection control: From testing the hot water, it was too hot to keep your finger under the water. The registered manager said the water temperature is regulated but she would look into this: The laundry door and office doors were wedged open – this creates a fire hazard: Oxygen cylinders are stored in the shed, under the stairs and one is in use in a bedroom. Appropriate signage must be displayed. The registered manager agreed to address these issues immediately. Photos of staff should be gained and placed on staffing files. Quality assurance summary should be complied from the recent survey and this plus the action plan should be forwarded to the Commission. The registered provider must complete monthly Regulation 26 reports as they are not in day-to-day management of the home. These reports inform the Commission, and the home as to what progress the home is making. 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 Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 9 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 Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission assessment procedure is good, and enables the registered persons to ascertain they can meet the needs of service users, before admission is arranged. Service users are able to make a informed choice about the home and if it is able to meet their needs. EVIDENCE: The registered manager assesses service users before admission is arranged. Information from the resident, their representative and relevant professionals is incorporated in the assessment. Residents confirmed that they visited the home and met with staff prior to admission and were informed about the facilities and services that the home offer. Copies of assessments were seen and were satisfactory. Copies of the Service Users Guide are placed in each resident’s bedroom. Residents commented that the admission to the home was carried out with sensitivity from staff and found it to be a positive experience. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. All service users have a satisfactory care plan, and these are suitably reviewed. These could be developed further to ensure service users’ care needs are met in a consistent manner. Access to healthcare is satisfactory and service users commented they are assured they will receive suitable support from medical practitioners. Issues regarding the diverse backgrounds of service users appear suitably addressed. Service users have said they feel they are treated with respect and dignity. EVIDENCE: Each resident has a care plan. All residents commented that they felt their physical and emotional care needs were met to a ‘good’ standard. They also felt that if their needs changed staff would listen to this and accommodate it. This was evidenced in the monthly review reports of which the registered manager stated she involved the residents. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 12 The care plans seen were satisfactory. Care staff said they felt they were understandable and as they knew some residents for a long time they knew their care needs well. In discussion with the registered manager it was acknowledged that whilst the care plans do identify care needs they may benefit from further expansion so that they inform, guide and direct staff on what interventions are needed. If an individuals needs are complex this will be needed so that staff ensure they all approach care in a consistent manner. The registered manager agreed to review them and discuss this with her staff team. All residents stated that they are confident about their ability to access external NHS healthcare services when they need them and staff will contact residents’ doctors on their behalf in response to specific needs. Individual documentation confirmed this. The home promotes good health and encourages residents to keep fit and active. Since the last inspection some improvements have occurred in the management of medication. The storage administration and disposal of medication was satisfactory. Inspection of MAR sheets demonstrated medication is administered appropriately. The Commission informed the registered manager that if they need to transcribe on the MAR sheets this should be witnessed by two staff members. The medication policy is satisfactory and in line with the Royal Pharmaceutical Guide. During the inspection it was noted that oxygen is in use, appropriate signage must be displayed where oxygen is in use or stored. The homes medication policy needs revision further to include the use of oxygen and homely remedies. A recent pharmacist audit (16/04/07) did not identify any concerns. Residents said they felt staff worked with them in a manner, which respected their privacy and dignity. Residents were positive about their care and stated that personal care was provided to a good standard. It was observed that the staff team are all female, male residents stated they had no concerns or issues with intimate care being provided by a female. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy a good quality of life in the home with access to activities arranged by the home and in the community. They are encouraged to maintain contact with their families and friends and arrangements are in place for them to make decisions about things that are important to them. Service users confirmed they enjoy the nutritious meals provided by the home EVIDENCE: Residents confirmed they could get up and go to bed when they wished. The commission observed staff working in an appropriate manner with residents. Residents said that the activities provided in the home are appropriate for them in terms of what they expect and enjoy doing. Residents were aware of organised activities that were occurring so that they could choose if they wish to participate or not. Residents’ interests are recorded in their files. The home’s manager said that are no restrictions on visitors at reasonable times. Residents confirmed that their friends and relatives are able to visit them either in their own rooms or in the communal areas of the home and they receive a ‘nice welcome’.
Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 14 Residents said that they are able to make decisions about things that are important to them. They are able to personalise their private accommodation and bring items of furniture with them in agreement with the registered provider. All residents commented that the food at the home was ‘good’ or ‘excellent’. One commented that Christmas dinner was ‘fit for the queen’. Lunch was observed to be an unrushed and social occasion in an attractive dining area with a pleasant atmosphere. Residents said they enjoyed the food and were given a choice of menu. If residents do not like the main meal on offer, an alternative is provided. A choice of a hot and cold evening tea is offered, with a variety of options available. Suitable records of food provided are maintained. Special diets (e.g. diabetic meals) are provided as required. It was noted that some residents were unaware of the meal choices for that day. This was discussed with the registered manager who stated that residents are asked the day before what they would like for dinner the next day, then on the following morning they are reminded what the options are. The commission suggested that a menu on display may assist residents in what is available. The registered manager said she would consider this. Catering staff have attended healthy eating courses so that they are better informed about nutrition. ‘Safer food better business’ is being implemented and training in this is being provided to catering staff. Records of food served to residents are kept. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are suitable procedures regarding complaints. The registered manager needs to make minor amendments to the adult protection procedure so that it is in line with the Multi Agency Adult protection Guidance so that service users can be assured the home will mange any incidents in a appropriate manner. EVIDENCE: All residents said that they were satisfied with the care and services provided to them and none had felt it necessary to make a formal complaint. They were unsure about the formal process, but said they would feel confident about taking any concerns to the home’s manager. The complaints policy is satisfactory. An adult protection policy is in place, however it needs minor amendments so that it is in line with the Multi Agency Adult Protection Procedure so that staff are aware of what action to take and which agencies to inform if they are concerned about the welfare and safety of a resident. The registered manager agreed to gain a copy of this document and to make the minor amendments needed. The registered manager has gained a ‘No Secrets’ video that is being shared with staff whilst they await places on the Multi Disciplinary Adult protection training. It is acknowledged that this is an oversubscribed course and therefore the registered manager is to be congratulated in undertaking some interim training measures whilst they await this. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,25,26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is attractive, and comfortable so that residents enjoy a homely and well-maintained environment for service users to live and feel at home in. The home was clean and tidy and staff were aware of the importance of infection control. Some improvements to the physical aspects of the home are needed to ensure that resident and staff health and safety is paramount. EVIDENCE: Mount Pleasant was observed to be well maintained, clean, pleasantly decorated and homely. There is a pleasant garden, which residents were using at the time of the inspection and commented that they like to spend time outdoors. There is a designated smoking area in the garden summerhouse. All residents can access the garden, as there are a variety of ramps that allow wheelchair and frame access. All communal rooms are homely and comfortable. There are two lounges downstairs and a dining area. The lounges were used and residents commented that they like to spend time in the lounge and socialise with other
Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 17 residents there. Residents commented that the home is ‘always kept clean’ and that they were ‘happy’ with their bedrooms, which were personalised. Attention has been given to the previous set requirements to ensure that all rooms are odour free and if there is a restriction in place regarding the use of en suites then this is risk assessed with relevant consultation between individuals concerned and documented. A stair lift is provided to assist residents to access all parts of the home. Suitable bathroom facilities are provided. Suitable kitchen and laundry facilities are provided. The home was clean and hygienic at the time of inspection. Staff were aware of the importance of infection control and COSH procedures. Some issues in respect of the environment were discussed with the registered manager: • Lighting in the kitchen and medical cupboard must be covered as currently the light fitting is exposed, if it breaks this would create a health and safety hazard to those working in those areas, plus splinters of glass may get into food and medical products. • The carpet on the top floor of the home and in room 15 is not laying flat leaving ridges, which could cause a tripping hazard. The registered manager said that it is planned that when the hallways are decorated that the carpets in these areas will be replaced. • Three bedrooms are identified as fire exits: risk assessments of the individuals that use these rooms in particular around accessing the fire escape stairs must be undertaken due to potential health and safety risks. • Paper towelling must be providing in toilet areas to promote infection control • The bathroom carpet (top floor) must be replaced to promote infection control • From testing the hot water, it was too hot to keep your finger under the water. The registered manager said the water temperature is regulated but she would look into this. • The laundry door and office doors were wedged open – this creates a fire hazard. • Oxygen cylinders are stored in the shed, under the stairs and one is in use in a bedroom. Appropriate signage must be displayed. The registered manager has organised for the majority of these cylinders to be removed. The registered manager agreed to address these areas immediately. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels appear to be satisfactory. Recruitment procedures and records are satisfactory so ensuring that all staff is vetted before working with vulnerable adults. Staff have attended training required by regulation so that service users are assured that staff have suitable skills and knowledge to cater for their needs. Equal opportunities issues regarding recruitment and work practices seem satisfactory. EVIDENCE: Rotas show three members of staff are on duty in the morning, two in the afternoon, and two staff in the evening until 2300. There is one waking night staff on duty, and one member of staff sleeping in. There is separate domestic, catering and management staff. Therefore care staff can dedicate their time to residents care. Since the previous inspection the registered manager has reviewed the teatime staffing levels. From her observations, plus discussion with residents and staff she has concluded that staffing levels are adequate at this time. From the Commissions discussion with residents they echoed this and felt that teatime remained an unrushed occasion and that all their needs were met. A staff member did state that on ‘some occasions’ it would be beneficial to have additional staff at teatime. The registered manager agreed that she is constantly reviewing the teatime arrangements and that if the resident’s needs became more complex then she would ensure that staffing levels reflected this.
Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 19 The registered manager is a NVQ assessor. Thirteen care staff out of sixteen has gained a NVQ qualification at a minimum of level 2. Staff records of three staff recently recruited to the home were inspected. These showed that appropriate checks had been undertaken and that the homes recruitment procedures were followed. The registered manager should ensure that photographs of staff are gained, she stated that it is planned that a ‘photo board’ for staff is being planned which will assist residents and visitors to identify staff members more easily. The registered provider’s approach to equal opportunities and anti discrimination is satisfactory. Staff stated, confirmed by documentation that there has been an increase in staff training. Recent training in the areas of food hygiene, infection control and manual handling has occurred. There are satisfactory records of staff induction. Staff supervision is recorded by the registered manager undertaking direct observations of staff care. The registered manager said that she undertakes a yearly appraisal where work and training issues etc are discussed in detail – a format of this was seen. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is suitably experienced and qualified to manage the home. The registered manager approach to quality assurance is good and should assist the management team to assess and improve the quality of service. The registered persons do not handle any moneys on behalf of service users. The management of health and safety issues is satisfactory therefore ensuring that the home is safe for those that live, visit and work at the home. The registered providers must produce a monthly regulation 26 report. EVIDENCE: The registered manager has suitable experience and knowledge to manage the home. Staff and residents all spoke highly of her management style and commented that they could approach her with ideas or concerns. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 21 The registered manager has a suitable quality assurance policy. The registered manager has completed a survey of residents, their representatives and professionals who use the service. The feedback has been positive in that the home provides satisfactory care and accommodation by a skilled staff team. The registered manager agreed to forward to the Commission a summary of the survey with an action plan. The staff team have received letters and cards of thanks from relatives for care given to residents. Staff and resident meetings have taken place. The registered manager does not look after any residents’ moneys or act as agents for service user government financial benefits. Residents confirmed that they have access to a lockable area in their room for small items of value. There was evidence that safety, including fire safety equipment is regularly checked and tested by competent professionals and the building is well secured at night to protect residents from intruders. The fire safety risk assessment has been reviewed and the homes manager said that the fire authority has approved this recently. The electrical hardwire circuit has been replaced and fire alarm systems updated. There are some issues in respect of health and safety, which is detailed in the environmental section. Accident records are suitably maintained. The risk assessments in relation to these are satisfactory but could be expanded further so that staff are aware of what equipment etc is required when they are needed to intervene. Since the previous inspection the registered manager has updated the homes policy regarding protective clothing, this is satisfactory. It was observed during the inspection that appropriate clothing was being used. The registered providers have not completed monthly Regulation 26 reports. This must be undertaken as they are not in day-to-day management of the home. This report will provide an overview of the service and will assist the registered manager as she continues to improve the day-to-day running of the home. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 23 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 OP19 OP25 Regulation 23 2(b)(c), 4 all 13 (3) Requirement The registered manager must ensure that the environment is safe for those who live, visit or work at the home and potential hazards are eliminated as detailed in the report. The registered provider must complete monthly Regulation 26 reports as required in the Care Standards Act 2000 Timescale for action 01/09/07 2 OP38 26 01/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The registered manager should review Service users care plans to ensure that they inform, guide and direct staff on what interventions are needed when providing care. The registered manager should review Service users risk assessments so that they detail what equipment is needed
DS0000009165.V338007.R01.S.doc Version 5.2 Page 24 2 OP7 Mount Pleasant when for example a Service users experiences a fall 3 4 5 6 OP18 OP18 OP29 OP38 The registered manager should make the relevant minor amendments to the adult protection policy as discussed. Arrange staff to attend local authority adult protection training. Photos of staff should be placed on staff files When completed the registered manager should send the finding of the quality assurance survey with an action plan to the commission. Mount Pleasant DS0000009165.V338007.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Devon Office Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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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