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Inspection on 21/01/08 for Mount Pleasant, St Agnes

Also see our care home review for Mount Pleasant, St Agnes for more information

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Generally people living in the home spoke positively regarding the support they received. People were also positive about the food provided and the choice of food that is available. Routines were viewed as relaxed. Staff are generally viewed as kind and caring.

What has improved since the last inspection?

Some repairs and redecoration has been completed. Some people who use the service said there are now more activities available. The registered provider`s Improvement Plan states other improvements have occurred in regard to matters outlined in the previous reports. However due to the termination of this inspection we were unable to assess whether the developments which have occurred are satisfactory.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Mount Pleasant Rosemundy St Agnes Cornwall TR5 0UD Lead Inspector Ian Wright Unannounced Inspection 21st January 2008 09:35 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 DS0000008913.V357308.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 DS0000008913.V357308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Pleasant Address Rosemundy St Agnes Cornwall TR5 0UD 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) 01872 553165 01872 553776 Mr Godfrey William Sear Mrs Susan Ann Sear Position Vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named service user under the age of 65 years (62 years) 3rd August 2007 Date of last inspection Brief Description of the Service: Mount Pleasant is located near the centre of St. Agnes. The registered providers are Mr G Sear and Mrs S Sear. Mount Pleasant provides accommodation and personal care for up to 22 older persons. The accommodation is on one level; there is full access around the home for people who use the service. Corridors are wide to suit people who use the service who use a wheelchair. There are 20 rooms of which 18 are for single occupation and two shared rooms. The majority of bedrooms have an en-suite toilet and washbasin facilities. Communal areas and rooms are decorated and furnished to a satisfactory standard. The kitchen area is clean and organised. The house is set in well laid out gardens, with pleasant views of the town and countryside. There is satisfactory parking for visitors. The home is close to local amenities with access to transport links into the main city of Truro. CSCI were not notified of the fee range at the time of inspection. A copy of this and previous inspection reports is available from either CSCI or the registered provider. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced key inspection took place in just over five hours in one day. This inspection was completed after the serving of a notice issued in accordance with paragraph 6.7 of Code B of the Police and Criminal Evidence Act 1984 (Code of Practice for the Searching of Premises and the Seizure of Property Found on Persons or Premises) for the period of the inspection between 09:52 and 15:02. The reason this was served was because the commission believed an offence, for example, under the Care Standards Act 2000(Care Homes Regulations 2001) may have been committed. The inspector explained the purpose and contents of the notice to the designated person in charge at the time of inspection. A copy of the notice was left at the home for the registered provider. The inspection ended when a member of staff informed the inspector that he had been directed by the registered provider to refuse access to the home’s records, and the inspector was subsequently asked to leave. The commission is currently seeking legal advice regarding this matter. Subsequently it was not possible to fully inspect all of the key standards. The methodology used for this inspection was: • Discussing with people who use the service they views of the service. • Observing care practices. • Inspecting the care environment. Other evidence gathered since the previous inspection such as notifications received from the home (e.g. regarding any incidents which occurred) were used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? Some repairs and redecoration has been completed. Some people who use the service said there are now more activities available. The registered provider’s Improvement Plan states other improvements have occurred in regard to matters outlined in the previous reports. However due to the termination of Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 6 this inspection we were unable to assess whether the developments which have occurred are satisfactory. 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 Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 8 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 DS0000008913.V357308.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inspector was denied access to records such as assessments and contracts of people using the service, so we cannot assure people that information gathered and provided will be of benefit to people who use the service. EVIDENCE: Although we were unable to inspect information regarding the statement of purpose / service user guide, assessment, and contracts, these were satisfactory when we completed a key inspection in August 2007. However these records must always be available for inspection. The inspector spoke to several people who use the service. People who were admitted to the service, since the last inspection, said they could not remember anyone completing an assessment before they moved in. One person however said they did visit the home before admission was arranged. The other people said either a social worker or another representative arranged the placement for them. A concern has been expressed to the commission regarding assessment procedures, however as we were unable to Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 10 assess any records or speak to senior staff regarding this matter, we are currently unable to make a judgement regarding this. Mount Pleasant DS0000008913.V357308.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 poor. This judgement has been made using available evidence including a visit to this service. The inspector was denied access to records such as care plans, and health care records. We therefore cannot assure people who use the service that arrangements for their health and personal care are satisfactory. EVIDENCE: Although we were unable to inspect care plans on this occasion, when we completed a key inspection in August 2007, these records were satisfactory and had improved significantly since previous inspections. On this inspection, although some people who use the service did not appear to be aware of their care plans, most people who use the service said the care they received was appropriate and carried out in a manner according to their wishes and needs. People said they could see a doctor or other medical practitioner when this is necessary. However we were unable to assess records regarding this matter. Part of the medication system was inspected. Medication is stored in locked a medication trolley, and also in a cupboard. The trolley is stored in the dining Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 12 room and the cupboard in the office. The inspector was told he could not inspect the medication stored in the office. The medication stored in the trolley was only partly inspected as the inspector had to terminate the inspection. Medication is administered via a monitored dosage system. The operation of the system is only adequate and the following improvements are required: • Some medication was administered, but not signed for (for example on the 20/1/08 night time and 21/1/08 breakfast) • Some medication was not administered but had been signed to state it had been administered. (for example haloperidol 20/1/08, and Senna 18/1/08 and 19/1/08). If any of this medication is refused, not required, or not administered for any other reason, the correct code should be recorded on the medication sheet and an explanation recorded on the rear of the medication sheet and in care notes. We were unable to assess whether staff have received training regarding medication. A requirement was issued at a random inspection on 26th September 2007 (report dated 1st October 2007). The registered provider’s Improvement Plan following the last key inspection stated staff would receive training. The Improvement Plan also stated the registered provider had also requested the pharmacist to visit the home, and after this all recommendations were complied with. However it is clear there are still serious errors occurring and any internal monitoring is not satisfactory. The requirement issued in the previous inspection report is subsequently renotified, and the commission is currently considering if enforcement action is required regarding this matter. People who use the service generally spoke positively regarding the attitude of staff, and said staff respected their privacy and dignity. However some people who use the service expressed some concerns: • One person said a member of staff would knock on the door, but would not wait to be asked to come in. • One person complained that staff or management would make decisions on behalf of them without consulting them. • Matters of concern regarding maintenance, heating and ventilation are not addressed. • A resident meeting was held where people who use the service brought up a number of concerns. Some attendees said they did not feel management subsequently addressed the matters of concern. When the inspector was speaking to people in the lounge, a member of staff came in and turned off the television without any discussion with people there. It was clear at least two people were watching it. This may have been done to assist the inspector who was talking to people in the room. However the member of staff did not check with either the inspector or people who were watching the television to ascertain if their action was appropriate. The Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 13 television actually did not present as a barrier to the discussions the inspector was having with people. Due to the inspection being terminated, the inspector was unable to discuss these matters with management or senior staff. We will however follow up these matters. It is essential the service provided is responsive to individual needs, and respect is given regarding people’s views (e.g. particularly since the implementation of the Mental Capacity Act 2005.) It should however be considered that other staff interactions were observed as positive, and no other concerns were expressed by staff or people who use the service to the inspector. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Routines, food and opportunities generally meet the needs of people living in the home, although some improvement is required to ensure people’s choices are respected. EVIDENCE: The inspector was able to speak to many of the people who use the service. All said they could get up and go to bed when they wanted to, and that routines were not rushed. The inspector also observed practices as relaxed. Some activities are available for example keep fit sessions, a clothes show (an external company coming in to sell clothes to the residents), a guitarist has visited and a fortnightly church service. Some people said there had been a meal out to the local pub before Christmas and events at Christmas were very nice. People had also received an offer to go to a pantomime, although there had apparently been little interest in this. One lady said ‘we have improved in this since you last came’ regarding the activities offered. Some people however said they were happy to spend time in their bedrooms reading or watching TV. It is understood the county council library visits the home for at least one person living there. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 15 People who use the service said they were able to receive visitors when they wished, either in one of the lounges or in their bedrooms. People who use the service said they felt they could exercise choice over their lives for example how to spend their time, what they could wear etc. Some concerns regarding enabling people to have choice are raised in the previous section, and the management need to address these issues. Due to the inspector being prevented from assessing records, on this occasion we were unable to assess arrangements for assisting people to manage their finances or arrangements for looking after valuables. These records must always be available for inspection. The inspector shared a meal with some people who use the service. Food served was of good quality and there was a choice available of main course and sweet for people. This is excellent as there is often only a limited choice in many care homes. The meal provided was stew or fish pie, followed by bread and butter pudding, and was very nice. People who use the service all said they were happy with the food provided. They said there was always enough food and meals were well cooked. A choice of evening tea is also provided, and hot and cold drinks are available throughout the day. Two people said they would appreciate their dinner plates being warmed before the meal was served. This matter was mentioned at the previous inspection, and though the people concerned said now their plates were sometimes warmed, this was not always the case. This should be implemented for the people who wish for this. The previous recommendation is therefore repeated. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. The inspector was denied access to inspecting policies and procedures. However were satisfactory at previous inspections, which should assure people who use the service that there are appropriate policies regarding complaints and protection. Concerns expressed about the provider’s attitude to dealing with concerns and complaints do not give us assurance these matters will be dealt with effectively. EVIDENCE: Since the last inspection in August 2007 we have received one concern, from several sources, which we were going to investigate as part of this inspection. As we were prevented from assessing records we have not been able to do this, although we will investigate the matter of concern in the near future. We were not able to view the home’s complaints records as they were not available for inspection. The inspector was also not able to assess procedures regarding complaints and adult protection, or what training staff have received regarding the prevention of abuse. Some residents have expressed concern that one of the registered providers does not take their concerns seriously or deal with them to their satisfaction. These issues are referred to in the standard regarding privacy and dignity, and a requirement has been made regarding these matters . People living in the home were positive about the staff group and said they were not aware of any poor or abusive practice. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 17 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, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements are required e.g. to ensure a satisfactory supply of hot water. With improvement the home will provide a suitable facility to meet the needs of people who use the service. EVIDENCE: The building was inspected. There is suitable shared space for example a large lounge and a dining room. Communal lounges are generally pleasant and homely. Corridors appear to have been redecorated and look attractive. Toilet and bathroom facilities are suitable in size and facilities provided, although some redecoration in these areas is still required. Bedrooms are generally decorated and furnished according to individual tastes. People who use the service said they were able to bring their own furnishings and belongings with them when they moved in. This helps to make the bedrooms individual and homely. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 18 Some of the double glazed windows have become clouded with patches of condensation. While this did not concern some people living in the home, some residents have expressed concerns to the inspector both on this inspection, and the previous inspection in August 2007. We are concerned no action has been taken despite discussion occurring at the previous inspection, and assurance in the registered provider’s Improvement Plan that all issues in the report dated 3rd August 2007 had been addressed. A requirement is subsequently issued regarding this matter. Concerns have been raised regarding there not being enough hot water in the home, and also regarding whether the home is kept warm enough. The inspector did ascertain that there is a problem with the hot water supply on the day of the inspection, particularly in part of the home. The inspector noted that the water was cold in the bathroom marked ‘ladies’ opposite Room 6. Water was also cold in at least two of the bedrooms, despite the inspector keeping the water running in each room for at least five minutes. The commission had to complete a random inspection in December 2006. One of the concerns raised was in regard to there being inadequate hot water available in some of the residents’ bedrooms in the morning. Some people who use the service did express concerns regarding this matter to the inspector at this inspection. An immediate requirement was issued in December 2006, and the registered provider confirmed in writing that appropriate repairs were then completed. It was of concern this matter has not been resolved or has become a problem again. Subsequently the registered provider must confirm in writing to the commission what action they will take to rectify the situation to ensure there is a satisfactory supply of hot water throughout the day. Failure to take appropriate action could result in enforcement action. A concern has also been expressed to the commission from visitors regarding heating in the home. On the day of the inspection the temperature seemed only adequate. Despite the heating being on it was a bit drafty in the lounge. Some of the residents had blankets over them. This may be due to these people’s age and them feeling the cold more. However a more appropriate response would be to install another storage heater(s) or change the heating to a central heating system. One resident did say it had been ‘a battle’ with the registered provider to have the heating on in August and September, when unseasonably poor weather resulted in people feeling cold in the home. The registered provider had apparently told people that the heating could not be turned on until October. As storage heaters can be individually controlled it is a concern that the registered provider did not assist the person(s) concerned. A person who uses the service also said they were not allowed to open their windows. The person alleged one of the provider’s would come to their room and shut their window if it was opened. The inspector has heard other people Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 19 complain about not being able to open the window on previous inspections. This matter was subsequently discussed with the provider previously. The registered provider must ensure people are allowed to have a choice whether they want their window open. If there are concerns about security, this can be addressed through risk assessment. The building was clean and hygienic on the day of the inspection. People who use the service said the home was generally kept clean and maintained appropriately. However currently a cleaner is not employed. The registered provider is recommended to employ a replacement for the person who has left as soon as possible. Laundry facilities are suitable. There was mixed feelings from people who use the service regarding the laundry service. Some people said it was good, although some people complained items had disappeared. The registered provider is advised to monitor arrangements and make improvements if they are necessary. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. On this inspection we have been unable to determine whether appropriate action has been taken regarding concerns expressed in the previous key inspection report dated 3rd August 2007. CSCI cannot subsequently assure people using the service that recruitment checks and staff training are to a satisfactory standard. EVIDENCE: On the days of the inspection there were three care staff on duty from 0700 to 1400, and two care staff on duty from 1400 to 2100. There is one waking night person on duty each night. The registered providers live in the neighbouring bungalow. On the day of the inspection we were told that Mr Sear was away and Mrs Sear had completed the night shift and was due to complete the forthcoming night shift. A cook and someone to help with the evening tea are employed. There is currently no cleaner and a recommendation to replace the person who has left has been made. The staff roster and record of hours staff have worked (which is kept in a diary) show there is satisfactory staffing provided. Staff informed the inspector that any staffing records were not to be made available to us for inspection. Requirements were made in previous reports regarding recruitment checks and staff training. In the last report we said enforcement action would occur if improvement did not occur. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 21 The registered provider stated in their improvement plan dated 23rd November 2007 that appropriate action had been taken to improve staff recruitment checks, staff induction and staff training. However, as we were prevented from inspecting appropriate records we could not evidence this. We therefore will be seeking legal advice regarding this matter and are renotifying the relevant requirements in the report. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 22 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 poor. This judgement has been made using available evidence including a visit to this service. On this inspection we have been unable to determine whether appropriate action has been taken regarding concerns expressed in the previous key inspection report dated 3rd August 2007. CSCI cannot subsequently assure people using the service that standards regarding management, administration, and, health and safety are to a satisfactory standard. EVIDENCE: The registered providers have owned and managed the home for a number of years. Mrs Sear said she has attended a City and Guilds Advanced Management Course, and an accountancy-training course. Mr Sear is from an electrical engineering background. The commission is concerned about the failure to make the required records available for inspection. The registered provider and/ or staff actions could be deemed as obstructing an inspection. Obstruction of an inspector is an offence under section 31(9) of the Care Standards Act 2000. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 23 We have raised concern about the availability of records on previous inspections. We have also previously notified the registered provider regarding the need to make available all records for inspection for example as outlined in our reports dated 3/8/07 and 26/9/07. The commission subsequently had a meeting with Mrs Sear on 20/11/07 as part of the commission’s Improvement Strategy. The registered provider was asked what action she would make regarding the requirements made in the previous report. The registered provider subsequently wrote to CSCI on 23rd November 2007 with an improvement plan. In regard to access to records the registered provider stated ‘All records required to be available at any time are now in the main office’… ‘Records deemed unsuitable to be in open files in office will be in locked cabinet. Key held by responsible person on duty.’ Mrs Sear confirmed this action was completed. Some of the people who use the service have expressed concerns regarding the attitude of one of the provider’s; particularly when they have concerns such as about repairs, hot water etc. as outlined elsewhere in the report. Concerns regarding these matters have been expressed in previous reports. There are concerns regarding the number of renotifications of some statutory requirements. In some cases enforcement action may now need to follow. Requirements were made in the key inspection report dated 3rd August 2007, and the report about the random inspection on 26th September 2007 dated 1st October 2007, regarding quality assurance and health and safety. The registered provider’s Improvement Plan dated 23rd November 2007 states appropriate action has been taken regarding these issues. However as the inspector was unable to inspect the home’s records we cannot evidence appropriate action has occurred. Subsequently the previous requirements have been renotified. Similarly we were not able to inspect records regarding residents’ monies so we are unable to ascertain if these are still appropriately managed. The registered provider was requested to complete the commission’s Annual Quality Assurance Assessment (AQAA) by 9th July 2007 (as stated in our letter dated 11th June 2007). A reminder was subsequently sent out on 19th July 2007, and a further reminder sent out on 10th January 2008. This document still has not been returned. Enforcement action could now follow if we do not receive this documentation by the deadline outlined at the end of this report. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 24 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 2 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X 1 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 1 X 1 1 Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 OP2 OP3 OP7 OP8 OP8 OP9 OP14 OP16 OP18 OP28 OP29 OP30 OP33 OP37 A person authorised by the Commission for Social Care Inspection (under the Care Standards Act 2000 s31) is also authorised to enter and inspect the premises and may make any examination into the state and management of the premises and treatment of patients or persons accommodated or cared for there as appropriate (For example the medication system). Intentional obstruction is an offence and could lead to prosecution. (Under the Care Standards Act 2000 section 31 and section 32) Timescale of 01/11/07 not met 3rd Notification DS0000008913.V357308.R01.S.doc Version 5.2 Page 26 Regulation 17(1),(2), (3) Requirement You are required to ensure that all records specified under Schedules 3 and 4 of the Care Homes Regulations 2001, are made available for inspection at all times. Timescale for action 18/02/08 Mount Pleasant 2. OP38 OP9 13(2) The registered person shall make 01/02/08 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (For example: Storage of medication needs improvement as outlined in the body of the report. Any staff administering medication must have training such as from a pharmacist). This will ensure the medication belonging to people who use the service is managed effectively. Timescale of 01/11/07 not met. Second Notification 3. OP10 OP14 OP16 OP24 12, 22 4. OP19 23 5. OP24 OP25 16, 23 The registered provider must ensure the care home is conducted in a manner which respects the privacy and dignity of people who live there. The registered provider shall ensure good personal and professional relationships are maintained between staff (including the registered providers) and people who use the service. (For example matters outlined in the report need to be appropriately addressed) Where the glass in some of the windows is clouded, the registered provider must replace the glass. This will ensure people who use the service can see out of the window. The registered provider must ensure: 1. There is a satisfactory supply of hot water throughout the home throughout the 24 hour period. DS0000008913.V357308.R01.S.doc 01/02/08 01/06/08 01/04/08 Mount Pleasant Version 5.2 Page 27 6. OP29 19Schedul e2 2. The home is heated appropriately according to the needs and wishes of people who use the service. 3. People who use the service can open / keep their window open as they wish. 4. The registered provider must provide the commission with a report detailing what action will be taken to address the problems outlined above. These measures will ensure people who use the service can have satisfactory hot water, heating and ventilation according to their needs and wishes. The registered person shall not 21/01/08 employ a person to work at the care home unless— (a) The person is fit to work at the care home. (b)Suitable records are obtained in respect of staff employed as specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001 are maintained (For example a Protection of Vulnerable Adults Check, a Criminal Records Bureau Check, two written references etc.) These records must be available for inspection. (Deadline of 01/11/07 not met Fourth Notification) The registered person shall ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. This must include suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. (For example this must DS0000008913.V357308.R01.S.doc 7. OP29 18. 19 01/03/08 Mount Pleasant Version 5.2 Page 28 include training as required by regulation such as fire, manual handling, infection control, food hygiene and first aid. ) 8. OP29 18(c)(i)(ii) Fifth Notification. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that the persons employed by the registered person to work at the care home receive— (i) Training appropriate to the work they are to perform including structured induction training; and (ii) Suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. (Previous deadline of 01/11/07 not met. Sixth Notification.) The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. (Previous deadline of 01/11/07 not met. 2nd Notification) The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. (Previous deadline of 01/11/07 not met. 2nd Notification) The registered provider must return a completed Annual Quality Assurance Assessment within the timescale given DS0000008913.V357308.R01.S.doc 21/01/08 9. OP33 24(1)(2) 21/01/08 10. OP31 OP33 9, 24(1)(2) 21/01/08 11 OP33 24 01/04/08 Mount Pleasant Version 5.2 Page 29 12. OP38 13, 23 Previously requested by CSCI on 11/6/07, 19/7/07 and 10/1/08 The registered person shall ensure that— (a) All parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety; (b) Unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. (c) The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; (d) Equipment provided at the care home for use by residents or persons who work at the care home is maintained in good working order; (For example there must be: The registered provider must confirm in writing guidance given by the Environmental Health Department regarding the servicing and testing of manual handling equipment, electrical hardwire (electrical installation) testing and portable electrical appliance testing. Ensure there is evidence that there are suitable measures to prevent legionella in place. Suitable documentation of appropriate testing must be in place. ) (Deadline of 01/11/07 not met. Third Notification) 21/01/08 Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 30 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. 3 4. Refer to Standard OP15 OP26 OP26 OP31 Good Practice Recommendations Staff should warm dinner plates for those people who wish this to occur. A cleaner should be employed Management should monitor laundry arrangements and arrange improvement so items do not get lost. The registered provider should complete National Vocational Qualifications in care and management at level 4. Mount Pleasant DS0000008913.V357308.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton 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 © 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 DS0000008913.V357308.R01.S.doc Version 5.2 Page 32 - 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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