Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 03/05/06 for Mount Pleasant, St Agnes

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

This inspection was carried out on 3rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Mount Pleasant provides a homely and comfortable environment for service users who live there. Service users are very positive about the care they receive, and have high regard for the carers employed. Care is individualised, and service users right to be treated with respect and dignity is encouraged. Service users are able to smoke in their own bedrooms (if they are safe to do so), and pets are allowed at the discretion of the management. Selfdetermination is encouraged. Food provided is to a high standard, there is a choice of main meal and tea each day. Management are regarded as kind and well meaning. Staff were observed as working well together, seemed kind, caring and professional.

What has improved since the last inspection?

The owners, Mr and Mrs Sear, have decided to move back to live at the adjacent property. They have also appointed a head of care. This will provide staff with more guidance, and hopefully enable some of the service shortfalls to be rectified. Most care staff have enrolled in a National Vocational Qualification in care. This will enable them to have a professional, nationally recognised qualification.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Mount Pleasant Rosemundy St Agnes Cornwall TR5 0UD Lead Inspector Ian Wright Key Unannounced Inspection 3rd May 2006 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 DS0000008913.V292615.R01.S.doc Version 5.1 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.V292615.R01.S.doc Version 5.1 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 275289 Mr Godfrey William Sear Mrs Susan Ann Sear Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 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 service users. Corridors are wide to suit service users who use a wheelchair. There are 20 rooms of which 18 are for single occupation and two shared rooms. The majority of service users’ bedrooms have an en-suite toilet and washbasin facilities. Communal areas and service users’ rooms are decorated and furnished to a good standard. The kitchen area has been upgraded, is clean and well ordered. The house is set in well laid out gardens, with fine 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. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Inspection took place over in just over twenty hours over two days. All of the Key Standards were inspected. The methodology used for this inspection was: • To case track six service users. This included interviewing the service users about their experiences and inspecting their records. • Interviewing four staff about their experiences working in the home. • Informal discussion with other service users and staff. • Observing care practices. • Discussing care practices with management. • Inspecting records and 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? What they could do better: This report has generated a total of eleven requirements. The registered provider is legally obliged to comply with these requirements as they are currently in breach of the law. The requirements include the need to improve: Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 6 • • • • • • Care planning and ensure care plans are regularly reviewed. Laundry arrangements as the current arrangements cause a significant amount of dissatisfaction among service users. Recruitment procedures and checks carried out on new staff Staff induction and training provision. Procedures to ensure all staff have a Criminal Records Bureau / Protection of Vulnerable Adults check. This will ascertain all staff are suitable to work with vulnerable people. Health and safety precautions required by law are carried out. For example health and safety risk assessment, and suitable checks on electrical appliances need to be completed. Regarding some of these requirements there have been a significant number of renotifications. For example the requirement to improve care planning, and ensure care plans are reviewed has been renotified on seven occasions. The requirements to improve pre employment checks and to obtain Criminal Records Bureau checks have both been renotified on four occasions. This is totally unacceptable. On this occasion the time scales have been extended. However unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescales may lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. The registered provider will need to provide an action plan regarding how they will comply with these requirements. A follow up inspection may be completed between the date of this report and a further Key inspection. The further Key Inspection will be completed before April 2007. The comments in this section are disappointing as in many ways Mount Pleasant offers a very good caring environment with high levels of satisfaction from service users and their relatives. It is hoped that the increased management presence will now address the requirements highlighted in the report. 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 DS0000008913.V292615.R01.S.doc Version 5.1 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 DS0000008913.V292615.R01.S.doc Version 5.1 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): 2,3,5 Service users are issued with suitable terms and conditions of residency at the time of admission. Quality in this outcome area is good and enables service users to be aware of their rights and responsibilities. Satisfactory visiting arrangements are in place. Quality in this outcome area is good and assists service users (and their representatives) to make an informed choice regarding moving to the home. The pre admission procedure is good and enables the registered persons to ascertain they can meet the needs of service users before admission is arranged. EVIDENCE: Copies of resident contracts were available for inspection in service user files (if privately funded). These are to a satisfactory standard. Mrs Sear assesses service users before they are admitted. Service users confirmed they could visit before formal admission was arranged. Service users said an assessment was completed before admission was arranged. Copies of assessments were available for inspection in service user files. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 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): 7,8,9,10 The care planning system requires some improvement to ensure care plans are comprehensive and regularly reviewed. Quality in this outcome area is adequate. The Commission for Social Care Inspection is concerned that action has not been taken after a number of repeated notifications. However based on the inspector’s observation of care practices, and statements made by service users to the inspector; service users can be assured that although documentation needs improvement, care practices are generally good. Health care needs appear to be met and service users have access to a range of health care services. Quality in this outcome area is good so service users can be assured their health care needs are met. The registered provider operates a suitable medication system and service users can be responsible for their own medication if this is appropriate. However evidence of medication training needs improvement. Quality in this outcome area is good so service users can be assured their medication is suitably managed. Service users feel they are treated with respect and dignity, and staff work with service users in a sensitive and professional manner. Quality in this outcome area is good. Service users can be assured their individual needs will be respected and they will be treated in an individual manner. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 10 EVIDENCE: Service users said they were not aware if they had a care plan, but all service users were very happy with the care they received. Staff said they were aware service users had a care plan, and said these are available to them. Care plans were inspected, and although basic, are satisfactory. Care plans take into consideration the diversity of service users needs for example service users’ mobility needs. However, there are some gaps in care plans which staff need to complete. There is no evidence care plans are reviewed, and this needs to be arranged; with service user input where possible. The Commission for Social Care Inspection has notified the registered provider previously on six occasions regarding this issue. On this occasion the time scale has been extended as indicated in the requirements made. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. Service users said they felt their health care needs are met. For example they said they have suitable access to a GP, dentist , optician, chiropodist etc. District nurses visit regularly. Mrs Sear said any medical interventions are recorded in care notes. A relative described the provider and staff as ‘very good when (their relative) was ill….the care is excellent….if (the relative) is ill, they will always let me know.’ The registered persons have developed a suitable policy regarding the handling of medication. Service users said they believed their medication was handled appropriately. The medication system was inspected. Storage and recording of medication is appropriate. The administration of medication was observed and was appropriate. Some service users are able to administer their own medication, and suitable procedures are put in place regarding this. Senior carers administer other medication. Staff the inspector spoke to say they had received suitable training regarding the administration of medication. Mrs Sear said all senior staff except for one, have recently completed medication training, but they have not yet received certificates. These must be available for inspection on the next Key Inspection later in the year. Service users said their privacy and dignity are respected. For example all service users the inspector spoke to said staff always knock on doors before entering, and personal care is given suitably. Although, for example, no service users from an ethnic minority there is evidence the registered provider respects the diversity of service user needs. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 11 For example a Methodist minister visits the home regularly. Service users are also allowed to smoke in their bedrooms as long as they are safe to do so. Service users can have a pet at the discretion of management. It is clear from discussion with service users, and observation of care practices, that service users are enabled to live individual lifestyles according to their preferences. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 12 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, 13, 14, 15 Service users lifestyles meet their needs and preferences. However some service users said they would like some trips out. Visiting arrangements are suitable so service users can receive visitors when they wish. Quality in these outcome areas are good so service users can be assured they have a choice how they wish to spend their time. Arrangements for service users to bring their personal possessions into the home, and arrangements to handle their money are good. Quality in this outcome area is good so service users can be assured their right to exercise choice and control over their lives will be respected. Suitable arrangements are in place to ensure service users receive a wholesome, appealing and balanced diet. Quality in this outcome area is good so service users can be assured they will receive a high standard of meals. EVIDENCE: Service users said arrangements for getting up and going to bed are flexible, and they are able to make choices regarding how they spend their time. Daily routines are also said to be flexible and tailored around individual needs. Service users said there was enough to do and there are some activities available such as craftwork, and an exercise group. The Methodist minister also visits regularly. Some service users said they are able to go out on their own, and some do some gardening. Many service users said they had regular Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 13 visitors (e.g. family and friends), and in some cases relatives will take them out. Some service users said they would like to participate in short trips out e.g. to have a cup of tea, or look at the sea. The service users concerned said they would be willing to financially contribute towards this. The registered provider said she would look into the possibility to this. Service users said their finances are either managed by themselves or by their families. The registered persons keep small amounts of money on service users’ behalf. Service users felt their valuables and money are safe in the home, although bedroom doors are not lockable. The registered provider or other staff does not act as an agent or appointee for any service user. The inspector shared a meal with service users, which was to a very good standard. Service users the inspector spoke to also said meals were to a good standard. Each day, there are two choices for the main meal, and a choice of sweets. Staff support at the mealtime was observed to be to a good standard. Portions of food are generous, although some service users said they would actually like less food on their plates as the large portions put them off. The registered provider should vary the quantities given to individuals considering individual service user wishes. One person also said they would like their plate warmed before food was served. Some service users complained at times some supplies ran out e.g. biscuits or eggs. The registered provider said she regularly went shopping. There was plenty of food available on the days of the inspection. An evening tea and supper is provided. Staff said special diets are catered for. Specific cultural needs are catered for where necessary. Hot and cold drinks are available throughout the day. Suitable records are kept of food eaten by service users. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 14 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, 18 The registered persons have developed suitable policies, procedures and practices regarding dealing with complaints and the prevention of abuse. Quality in these outcome areas is good so service users can be assured any concerns, complaints and allegations of abuse will be dealt with effectively. EVIDENCE: The registered persons have developed a suitable complaints procedure. This is issued to service users as part of the service user guide. Service users said they felt confident approaching staff or management if they had any concerns or complaints, and felt these would be resolved effectively. The registered persons have developed a suitable adult protection policy. Service users said they had not experienced or witnessed any abusive behaviour from staff or others. Staff working in the home said they had not witnessed or heard about any abusive behaviour. Staff demonstrated a suitable awareness of what to do if they became aware of an abusive incident. Some staff have attended training regarding abuse and adult protection. The registered providers said they were unhappy with how an adult protection issue was dealt with by Cornwall County Council. The inspector has written to Cornwall Council to enquire about this issue as the council’s response did seem inadequate. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 15 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): 19, 26 The building appears to be suitable for its purpose as a care home and is well maintained. Quality in this outcome area is good so service users can be assured they live in a pleasant and homely environment. The home is generally clean, pleasant and hygienic although laundry arrangements need improvement. It is also recommended a cleaner is employed. Quality in this outcome area is adequate. Improvement is required so service users can be assured laundry and cleaning arrangements are satisfactory. EVIDENCE: The building was inspected. There is suitable shared space for example a large lounge and a dining room. Toilet and bathroom facilities are suitable. Bedrooms are decorated and furnished according to individual tastes. Service users said they were able to bring their own furnishings and belongings with them when they moved in. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 16 The building was clean and hygienic on the day of the inspection. Service users felt the home is kept clean and maintained appropriately, although some people the inspector spoke to were disappointed a cleaner was currently not employed. The registered provider said a cleaner would be employed, but the post had been frozen when the last cleaner left due to the service user vacancy rate. Laundry facilities are suitable, however some service users said they were unhappy with laundry arrangements. For example some items got lost which could be frustrating. The registered provider said she was to address the issuefor example name labels have been purchased and will be put on clothing. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 17 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): 27,28,29,30 Staffing levels are maintained appropriately. Quality in this outcome area is good so service users can be assured they will receive suitable levels of support from staff. Recruitment practices and records are unsatisfactory. Quality in this outcome area is poor. Funders, service users and their representatives cannot be totally assured service users will be protected by the registered persons recruitment practices. However service users were positive about staff employed. The staff the inspector observed and spoke to seemed professional and caring. The registered provider has a suitable approach to assisting staff obtain a National Vocational Qualification. Quality in this outcome area is good so service users can be assured staff are given the opportunity to receive a professional qualification in care. However other training practices are unsatisfactory. Quality in this outcome area is poor. Improvements need to be made so all staff receive training required by regulation, and regarding service users’ needs. Currently service users could be put at risk, for example, by staff not receiving training in epilepsy, food hygiene and infection control. EVIDENCE: The registered persons said staffing provided is at least: • Three members of staff on duty in the morning • Two members of staff on duty in the afternoon / evening Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 18 • One waking staff on duty overnight. The registered providers live in the neighbouring property and are available ‘on call’ out of hours. A cook is employed. The cleaner post is currently frozen. The inspector feels staffing levels were satisfactory on the days of inspection. However a recommendation has been made regarding the employment of a cleaner. Service users and staff the inspector spoke to felt staffing levels were satisfactory although some said a cleaner should be employed. Rotas provide accurate records of staff on duty. Service users held staff in high regard. Comments included ‘they are outstandingly good,’ ‘first class,’ ‘marvellous’ ‘they are very kind’ etc. Another service user said ‘staff are kind and patient….there is a warmth here, staff will come and talk with me…’ Staff said there was a supportive atmosphere among the staff team, and staff turnover is low. The registered persons outlined a satisfactory recruitment process. The registered provider has a suitable equal opportunities policy. However staff records required by regulation are unsatisfactory. For example, although each member of staff’s files contain a completed application form, there is no evidence Criminal Records Bureau / Protection of Vulnerable Adults checks have been completed. Criminal Records Bureau checks / Protection of Vulnerable Adults checks must be obtained for all staff employed as a matter of urgency. The registered providers must supply a list to the Commission of the disclosure numbers of all persons currently employed. This must be completed by the end of June 2006. Staff files inspected also did not contain two written references or evidence of staff induction. These records must be obtained for all staff employed from the date of this report. The Commission for Social Care Inspection has notified the registered provider previously on three occasions regarding these issues. On this occasion the time scale has been extended as indicated in the requirements made. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. Staff said they are offered the opportunity to pursue a National Vocational Qualification in care, and currently most of the staff are completing an NVQ 2 or 3. Staff the inspector spoke to outlined a number of training opportunities they had or could attend. Staff the inspector spoke to seem aware of fire procedures and a record is kept of when fire instruction is given. One member of staff outlined a thorough induction process. However there is no documentary evidence of staff induction. The Commission must be able to see evidence (e.g. an induction checklist) that all staff that commence employment from the date of this report receive an induction. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 19 The registered provider’s approach to ensuring staff have training required by regulation needs improvement. By law all staff must have moving and handling, fire and infection control training. The law also states there must always be one approved first aider on duty (this was the case on the days of the inspection), and all food handlers such as the cooks, and care staff handling food, must have a food-handling certificate. Records inspected show some gaps in this training and some certificates were not available for inspection. The registered provider said moving and handling training had recently been completed for all staff, and she was awaiting certificates to evidence this. Some certificates were available to evidence that some staff had attended an ‘Approved Persons’ first aid course. There was no evidence staff had completed food hygiene and infection control training. However staff the inspector spoke to seemed to have a good awareness of infection control procedures. No certificates were available for inspection regarding medication training. This training must be provided to all staff that handle medication, and there must be evidence of attendance (e.g. certificates). The requirement from the previous inspection that staff must receive training in epilepsy, so they can meet the needs of service users with this condition, is repeated as there is no evidence this has been delivered. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The registered providers are suitably qualified, experienced and skilled to manage the home, although some improvements need to take place to improve response to CSCI statutory requirements, general organisation and management systems. Quality in this outcome area is adequate but improvement is necessary so service users can be assured the home is managed satisfactorily. The registered persons have a suitable approach to quality assurance although the registered providers should introduce resident meetings, and ensure an improvement plan is developed, as part of the quality assurance process. However quality in this outcome area is good so service users can be assured their views will be listened and responded to. The management of service user finances is appropriate. Quality in this outcome area is good so service users can be assured their valuables and finances are managed appropriately. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 21 Health and safety precautions need some improvement. Quality in this outcome area is adequate, and improvements need to be made so all staff and service users can be totally assured the building is safe. EVIDENCE: Staff and service users were generally positive regarding the registered providers. Comments included the providers being ‘nice and friendly,’ ‘friendly and approachable,’ ‘will muck in,’ ‘fair,’ ‘marvellous’ However management and organisation were described as at times ‘lackadaisical,’ ‘rather loosely slung together,’ ‘things need tightening up abit.’ A couple of service users did not know who the owners were. The owners have moved back to live in a neighbouring property in the last few weeks, and also have appointed a head of care. This is a significant improvement. The providers seem friendly and approachable, and their return is welcomed by staff and service users. The difficult task they now have is to improve practices where necessary (e.g. care planning, some aspects of organisation, and staff recruitment and training) whilst maintaining the positive culture, good practices and positive relationships that exist. There are concerns regarding the number of renotifications of some statutory requirements. In some cases enforcement action could result if no action is now taken. The registered providers have a suitable quality assurance policy. A quality assurance survey was completed in June 2005. Comments regarding the home were generally positive although improvements were requested regarding cleaning of bedrooms and laundry arrangements. It is recommended an improvement plan is always completed regarding any quality assurance survey. The introduction of regular residents meetings would assist in ascertaining service users’ views, and provide an additional means of developing communication between management and service users. The registered providers have a satisfactory policy regarding the management and handling service users’ monies. The inspector spoke to several service users who said either they or their relatives look after their money. Service users said safekeeping facilities were available if they wished to use them. Some small amounts of cash are kept on behalf of service users for which appropriate records are kept. The registered persons have a suitable health and safety policy. Service users and staff believe the home to be a safe environment. A health and safety consultant completed a survey in September 2005, and highlighted a number of requirements for the registered provider to comply with the law. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 22 Health and safety records were inspected. Fire records evidence emergency call points and lighting is checked at suitable intervals. A fire safety risk assessment is also in place. A contractor checked the fire extinguishers in November 2005, and the fire alarm system has also been serviced at least annually. The Environmental Health Officer (Food) has also visited and made a number of requirements (e.g. the cooks must have a food hygiene certificate.) Accident reports are kept satisfactorily. Mr Sear, who has an electrical engineering background, checks and services the hoists, electrical hardwire (electrical installation) circuit and portable electrical appliances. The registered provider must check with the Environmental Health Department (health and safety), whether it is satisfactory for him to complete these tests or whether they need to be completed by an external contractor. Correspondence regarding these issues needs to be available for inspection. The portable electrical appliances were last tested in July 2004 and need to be tested at least annually. There is no record regarding testing the electrical hardwire (electrical installation). This needs to be tested at least every five years. The registered provider also needs to develop a suitable health and safety risk assessment procedure. Although the registered providers have a policy regarding the prevention of Legionella, they need to develop a risk assessment outlining suitable control measures. A current insurance certificate was not displayed. The registered provider said the insurance had been renewed but a new certificate had not been obtained. This must be obtained and displayed. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 23 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 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 24 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 OP7 Regulation 15 Requirement The registered person must: i) keep the service users plan under review in consultation the service user and/ or representative. ii) Make the service users plan available to the service user and /or representative and notify them of any revision. iii) ensure care plan documentation is fully completed. Previous deadline of 30/4/06 not met. Seventh Notification. 2. OP26 16 Laundry arrangements need improvement so clothing does not get lost. The registered person must review the organisation of the laundry system, and ensure clothing is labelled. 30/06/06 Timescale for action 30/06/06 Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 25 3 OP29 17 The registered person must retain in the care home the staff records listed in Schedule 4.6. Previous deadline of 30/3/06 not met. Fourth Notification 30/06/06 4 OP29 19 The registered providers must obtain appropriate information required by regulation for all new staff employed from the date of this report. The registered person must: 30/06/06 • Obtain Criminal Records Bureau disclosures for all persons employed. • Provide a list to the Commission of the disclosure numbers of all persons currently employed. Previous deadline of 30/3/06 not met. Fourth Notification 5 OP30 18 6 OP30 18 The registered provider must provide evidence of staff induction (e.g. an induction checklist). A completed induction checklist must be available for inspection for all staff that commence employment from the date of this report. Training in epilepsy must be provided to individual staff so they can provide this care appropriately. Previous deadline of 30/4/06 not met. Second Notification 01/06/06 30/06/06 Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 26 7 OP30 23 Mandatory training for staff must occur - especially in the areas of infection control, moving and handling, food hygiene, and first aid. 30/06/06 8 OP31 9 OP38 10 OP38 11 OP38 The registered provider must address the outstanding requirements in this report and provide the Commission with an action plan how they will do so. 13, 23 The registered provider must: • Check with the Environmental Health Department whether it is satisfactory for the provider to complete the electrical hardwire (electrical installation) testing and portable electrical appliance testing, or whether these tests need to be completed by an external contractor. Correspondence regarding these issues needs to be available for inspection. • Ensure portable electrical appliances are tested at least annually. • Ensure the electrical hardwire (electrical installation) circuit is tested at least every five years. 13, 23 The registered provider must develop a health and safety risk assessment procedure. Risk assessments must include the prevention of Legionella and include suitable control measures. 13, 23, 25 A current insurance certificate must be obtained and displayed. 9 01/06/06 30/06/06 31/08/06 30/06/06 Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 27 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 5 Refer to Standard OP12 OP15 OP27 OP33 OP33 Good Practice Recommendations The registered provider should look into the possibility of arranging trips out for service users. These should take place as necessary. The registered provider should vary the quantities of food provided to individuals based on individual needs and preferences. A cleaner / laundry person should be employed. An improvement plan should be completed as part of the annual quality assurance survey. The registered provider should introduce regular residents’ meetings as an additional means of ascertaining service user views about the service. Mount Pleasant DS0000008913.V292615.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 DS0000008913.V292615.R01.S.doc Version 5.1 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!