Inspection on 18/05/05 for Mount Pleasant Care Home

This inspection was carried out on 18th May 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 Pleasant Care Home 04/11/08

Mount Pleasant Care Home 23/10/06

Mount Pleasant Care Home 28/09/05

Mount Pleasant Care Home 28/10/04

Mount Pleasant Care Home 25/05/04

Mount Pleasant Care Home 29/04/03

Mount Pleasant Care Home 07/01/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mount Pleasant Care Home Off Hollow Lane WInshill Burton on Trent, Staffordshire DE15 0DR Lead Inspector Claire Williams Uannnounced 18 May 2005 8.30am th 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 Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mount Pleasant Care Home Address Off Hollow Lane, Winshill, Burton on Trent, Staffordshire DE15 0DR 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) 01332 546777 Willow Care Limited Denise Joan McManus Care Home with Personal Care 39 Category(ies) of 30 OP - Older People and 5 PD- Physical registration, with number Disability of places Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Thirty-nine persons of either sex, of which no more than five persons may be in the category PD over the age of 55, and the remaining persons to be in the category OP. Plus three (3) Day Care places. Date of last inspection 28th October 2004 Brief Description of the Service: Mount Pleasant is a Care Home registered to provide personal care and accommodation for up to 39 people in the category of Older Persons. Mount Pleasant is also registered to provide 5 places for people with a physical disability. Mount Pleasant is a purpose built building which is located on the outskirts of Burton-on Trent. The home is set in spacious grounds, and has a car- park. The home has all single rooms, all with en-suite facilities. A variety of lounge and dinning room space is provided. There are sufficient bathing facilities to meet the needs of the service user group. The Registered Providers have submitted plans to extend the building and increase the numbers of service users accommodated at the home. The building work had commenced at the time of this visit. Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 8.30am and lasted 7 hours. The inspector examined care, training and staff records, spoke with 13 service users and 2 staff who were on duty, The inspector also spent time with the Registered Manager and two of the directors responsible for the running of the home. The inspector also visited the ‘new building’, which is currently under construction. What the service does well: What has improved since the last inspection? The Registered Manager, and the staff team have worked hard to improve the care plans for the service users. All care plans have been updated and new documentation implemented including assessments on Tissue viability and falls assessment. The staff now complete regular entries into service users care records, and ensure that records are maintained when a service user is unwell or has had a significant event occur in their life. The care plans and paperwork are reviewed on a monthly basis, and the Registered Manager audits all files and care logs on a regular basis. Some staff and the Registered Manager have completed an accredited medication course, and an assessment of medication competence has been devised and will be implemented shortly. This training will ensure that the staff Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 6 team have the knowledge and skills to administer medication appropriately and in accordance with the relevant legislation. 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 Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4, and 5 Service users are assessed prior to admission, and the records supported that their needs could be met by the home. Service users can visit the home on a trial basis in order to assess the quality, facilities and suitability of the home. (Standard 6 does not apply to this Home.) EVIDENCE: The inspector examined three service users files, and spoke with these service users. All files contained the appropriate pre-admission assessments and correspondence concerning whether the home can meet the individuals support needs. Service users informed the inspector that trial visits such as ‘respite’ enabled them to see “what it actually was like to live there” before making a decision about their longer term needs. Emergency admissions are accepted and the required paperwork completed within 5 working days in accordance with the National Minimum Standards. Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 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, and 10 Improvements have been made to ensure that service users health, personal, and social care needs are identified and met. Service users health care needs were assessed and planned for. Service users are treated with respect and dignity. EVIDENCE: The Registered Manager and the staff team have worked hard in order to implement new paperwork and improve the care plans since the previous inspection visit. The inspector examined three service user files. Care plans were in place for the service users, which enables the staff to deliver appropriate care. All service users have received a falls and tissue viability assessment, and these have been reviewed accordingly. The falls assessments were sent to the National Osteoporosis Society who gave feedback and recommendations about each individual assessment, including contacting service users GPs. Risk assessments were completed and reviewed accordingly. Improvements have been made in the recording of information in the service users case records. The entries are now consistent detailing the support provided and the general well being of the individual. The Responsible Manager audits these records on a daily basis and signs to verify this. Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 10 All three files have been reviewed on a monthly basis and records completed. However there was no evidence to suggest the involvement of service users in these reviews or their access to their files. The Registered Manager is working towards ensuring that every service user has a formal review at least every six months. The inspector spoke with many service users who made positive comments about the staff team and the Registered Manager. All service users felt that their needs were more that “adequately met” by the staff team. Service users stated that their dignity and privacy was “always respected”, and commented that the staff team were “wonderful”, and “caring”. One service user who visited the home for a ‘respite break’ said that ‘she has had a wonderful holiday’ and would recommend the home to anyone. Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 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, 13, and 14 Social activities are well managed, creative, and provide daily variation and interest for the service users. Service users contact with families and friends is well maintained. l EVIDENCE: Service users informed the inspector about the variety of activities which are organised within the home. One service user commented on how much she enjoys the movement to music, which is facilitated by an external qualified individual on a weekly basis. An activities co-ordinator was employed at the home but has recently left her position, and the Responsible Providers are having difficulties recruiting another suitable individual. Therefore the activities are currently organised by the care staff on a daily basis for the service users to participate in if they choose to. Activities available for the week are displayed on the notice board. Discussions with service users confirmed that they are encouraged to exercise personal choice and autonomy in the home. Service users choose how they wish to spend their day, and stated that routines are flexible within the home. Service users also confirmed that the staff team encourage and assist them to maintain contact with their relatives or representatives and records confirmed this. Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 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) None of these standards were assessed during this inspection. EVIDENCE: Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 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, 20, 23, 24, 25 and 26. The home is equipped, furnished and maintained to a high standard and offers homely and spacious facilities for service users to enjoy. EVIDENCE: The service users spoke positively about the standard of the environment and the general cleanliness of the home and made comments, which included; “the home is decorated, lovely and is homely” “the garden and views are beautiful”, the home “always smells nice”. The inspector was invited to view some of the bedrooms by the service users. All bedrooms were personalised with service users own belongings, and had the appropriate fixtures and fittings available. One service user who was visited in her room had a telephone installed enabling her to maintain contact with her family. Building work has commenced at the home in order to extend the current property. The inspector undertook a site visit of these premises, and will be monitoring the progress of the work in the forthcoming months. Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 14 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) 28, 29, and 30 The recruitment procedures require some amendments in order to ensure that they protect the service users living at the home. The staff team have access to training opportunities, which enable them to obtain the skills and knowledge in order to support and protect the service users. EVIDENCE: The inspector examined three staff files, which contained all of the required information and documentation. The application form however needs to be updated in line with the amended regulations to request a full employment history, and written explanation of any gaps in employment. All new staff receive a comprehensive induction and foundation training programme, and then they are encouraged to work towards a National Vocational Qualification (NVQ). The inspector was informed that the home currently has 9 staff who have completed an NVQ level 2 and 3 staff who are currently undertaking the award. The home will therefore meet the required ratio of 50 of its staff team being trained to this level by the end of 2005. The staff members spoken to confirmed their access to training opportunities, and the encouragement and support they receive from the Registered Manager and the Responsible Providers. Training records are maintained, and demonstrated that staff have received training in the required mandatory courses in addition to service specific training. Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 15 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) 31, 32 and 36 The Registered Manager was experienced, competent and provided clear leadership and had good management skills. Staff supervision was provided. EVIDENCE: The Registered Manager was able to demonstrate her competence throughout the inspection by her knowledge of the service users, the home, the policies and procedures, and the strengths and shortfalls of the service provision. Both staff and service users spoken with felt that Registered Manager was accessible and approachable. Service users stated that the Registered Manager listened to them and acted on what she was told. Staff stated that the Registered Manager was “very supportive and enabling” and “helpful” to them in their role. Staff confirmed that they receive regular formal and informal supervision with the Registered Manager. The Registered Manager is currently completing the NVQ level 4 in management. Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 16 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 x 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 x x x 3 x x Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 17 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 7 Regulation 15(1) Requirement The registered manager must ensure that service users are consulted and involved in the development of their care plan. The application form must request an applicants full employment history, and written explanations of any gaps in employemnt. The applicant should record the reasons for leaving each employment. Timescale for action 31st September 2005 31st September 2005 2. 29 19 (1) (b) (i) and Schedule 2 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 Good Practice Recommendations Mount Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby DE1 3QT 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 Pleasant Care Home D52-C02 S20058 Mount Pleasant V225588 180505 Stage 4.doc Version 1.30 Page 19 - 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. 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