Inspection on 28/09/05 for Mount Pleasant Care Home

This inspection was carried out on 28th September 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 18/05/05

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 Unannounced Inspection 28th September 2005 09:15 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 Care Home DS0000020058.V254476.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 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 DS0000020058.V254476.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mount Pleasant Care Home Address Off Hollow Lane Winshill Burton On Trent Staffordshire DE15 0DR (01283) 546777 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) Willow Care Limited Vacant Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Physical disability (5) of places Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 18th May 2005 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 and was near completion. Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second inspection visit this year, and was undertaken due to the Commission for Social Care Inspection receiving a complaint. The inspector therefore undertook an unannounced inspection in order to investigate the issues from the complaint, and to examine key areas that are required to be assessed within a 12-month period. The inspector also had a brief tour of the extension that is currently being built. The inspection lasted 5 hours and the inspector looked at medication practices, polices and procedures, residents finances, and recruitment of staff. The home currently does not have a manager in place; the deputy manager is acting up into this role, and assisted the inspector with the inspection. The inspector also spent time with the Registered providers of the home. For the purpose of this report the people living at the home will be referred to as ‘residents’. What the service does well: What has improved since the last inspection? What they could do better: The staff team need to improve the recording of medication administered to residents, as there were many gaps in the medication charts. The acting manager needs to ensure that all valuables and money handed in for safe keeping by residents are recorded appropriately onto financial transaction sheets safeguarding residents valuables. The Responsible Providers need to ensure that they check the application forms to ensure that the applicant has supplied a full employment history. If this has not been provided then the Registered Providers must obtain a full employment history from the individual. The Registered Providers must ensure that when recruiting catering Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 6 staff they check to ensure that individuals have the required qualifications for their role, or are sent onto training courses before they undertake their role to ensure they have up to date qualifications. 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 DS0000020058.V254476.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 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 the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 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 the following standard(s): 9 and 11 The recording of medication does not ensure that resident’s welfare is safeguarded. The staff team respond sensitively to resident’s death. EVIDENCE: The inspector examined the Medication Administration Charts (MAR charts) for all of the residents in the home. Although the Mar charts were generally well completed the inspector did identify several gaps in the recording of the medication administered to residents, and these were unexplained. There was also couple of medication records that did not have the actually amount of medication administered when the medication was a variable dose. The home had received a pharmacy inspection on 28/7/05 and recommendations were made, which the Acting Manager confirmed would be addressed. The home had a recent death and the inspector and the Acting Manager discussed the procedures for supporting people through this sensitive time. The staff team undertake training in ‘Care for the dying’ and some of the staff members have attended the local undertakers in order to have an insight to this process. Protocols are in place to give guidance to the staff team, and the Acting Manager provides support to staff members following a death. Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12 and 15 Service users have the opportunity to access recreational activities of their choice, and enjoy the meals provided at the home. EVIDENCE: The residents informed the inspector on her arrival that they were going out for a pre-dinner drink at the local pub. The residents were to be transported there by the use of community transport. On their return the residents stated how much they had enjoyed the outing. Comments from residents confirmed that they felt they had access to appropriate recreational activities, and that any forthcoming events were displayed on the notice board. Residents have access to a hairdresser who visits the home each week. The inspector joined the residents for their lunchtime meal. The residents spoke positively about the quality of the food and confirmed that choices are always available on the menu. The staff team ask residents their preference of food at the beginning of each day. The inspector undertook a tour of the kitchen. All of the equipment was in working order, and the food stocks were satisfactory. The home has recently employed new catering staff, and one of the new cooks was on duty. Unfortunately the cook could not locate the records of the temperatures of the fridge and freezers, and she was not routinely keeping the records of the food taken by residents. Although the cook had previous experience and qualifications, unfortunately her food hygiene Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 11 certificate was out of date. The cook informed the inspector that she was to attend a course the following week. The inspector was informed that residents have access to fruit by asking the catering staff for it. The inspector did recommend that a fruit bowl be placed in the dining areas at each mealtime to enable residents to access independently. The home had an Environmental Health inspection on 20/5/05 and some recommendations were made, these have been addressed by the home. Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Residents felt that their complaints were listened to. Resident’s welfare is safeguarded by the homes adult protection procedures. EVIDENCE: A complaints procedure was in place, and this is displayed around the home. Residents spoken to stated, “if they felt the need to make a complaint, they would be listened to and the matter would be dealt with”. The inspector checked the complaints record, which was satisfactory. The home has not received any complaints this year. The Commission for Social Care Inspection has received one complaint about the home, and the inspector undertook an investigation into the complaint during this visit. The home has the required polices and procedures in place for the protection of Vulnerable adults. The inspector discussed the procedure that must be followed in the event of an incident being reported, with the Acting Manager, who is aware of her responsibilities. The staff team receive training in abuse and in the whistle blowing procedures. Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 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 the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 The deployment and the experience of the care staff team are sufficient to meet the resident’s needs. Residents are not safeguarded by the recruitment procedures at the home. EVIDENCE: Residents spoken to confirmed that the staff team are “always around to assist them in their daily lives”. Residents commented positively about the staff team and stated that they are “very caring and supportive”. Discussions and observations of the staff team confirmed that they have a good knowledge of the residents support needs and preferences. The rota for the previous week commencing 19th September 2005 was obtained. The care, catering, and domestic hours were satisfactory, and in accordance with the staffing levels agreed by Derbyshire County Council (the former regulatory body) at the point of transfer to the National Care Standards Commission, now The Commission for Social Care Inspection on 01/04/2002. The inspector examined three staff files. Although the application form has been updated to request a full employment history, only one out of the two files actually had a full history recorded. The two other files had some employment details but these had not been explored to ensure that a full history was obtained. All files contained at least two written references, and CRBs have been processed. One of the staff members recruited was for a cook’s position, and as mentioned previously her food hygiene certificate was out of date when she commenced employment. Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 Appropriate systems were not in place to safeguard Residents finances. The Health and Safety of residents is promoted and protected. EVIDENCE: The inspector was informed that a quality assurance survey has been undertaken this year in order to obtain feedback from residents about the quality of the services provided by the home. The Registered Provider does intend to analyse these results and complete a report of the findings. The inspector checked the financial systems within the home. Majority of the residents managed their own finances independently and there is lockable storage within each resident’s bedroom. There was one resident’s money being held for safekeeping by the home. Although this money was locked away, there was no financial transaction sheet recording the date and the amount of money handed in. A sticker recording the balance was attached to the purse but when the contents were checked the balance was above the amount Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 16 recorded. The Acting Manager did complete a recording system for this money following the advice of the inspector, and she also recorded other valuables that had been handed in for safekeeping by residents. A policy is in place detailing the safe handling of residents money. The inspector checked some of the Health and safety systems within the home. These included; gas certificate, electrical wiring certificate, Pat testing of all electrical appliances, insurance, hoist and lift safety checks, and fire procedures. All were satisfactory and in date. The Registered Provider is currently updating the Fire Risk assessment. Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X X 3 Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 18 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 OP9 Regulation 13 (2) Requirement The Registered Persons must ensure that all medication administered is recorded on the Mar Chart The Registered Persons must ensure that when a medication is a variable dose, the actually dose administered is recorded on the Mar Chart The Registered Persons must ensure that the fridge and freezer temperatures are recorded and monitored daily. The Registered Persons must ensure that when recruiting catering staff they have the required qualifications, which are up to date in order to fulfil their role. The Registered Persons must ensure that a full employment history is obtained from all applicants that apply for a position within the home. The Registered Persons must ensure that all valuables or money handed in for safekeeping is recorded and checked in accordance with the policies and DS0000020058.V254476.R01.S.doc Timescale for action 30/12/05 2 OP9 13 (2) 31/12/05 3 OP15 16 (2) (g) 30/11/05 4 OP29 19 (5) (b) 31/10/05 5 OP29 19 (4) (i) 30/11/05 6 OP35 16 (2) (l) 31/10/05 Mount Pleasant Care Home Version 5.0 Page 19 procedures of the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP15 Good Practice Recommendations The Responsible Person should consider providing a fruit bowl at all mealtimes to enable residents to help themselves to fruit. The catering staff should keep the food taken by residents for a period of time for monitoring purposes. Mount Pleasant Care Home DS0000020058.V254476.R01.S.doc Version 5.0 Page 20 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 © 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 DS0000020058.V254476.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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