This inspection was carried out on 17th February 2006.
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 found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Mount Vernon Terrace Care Home 23-25 Waverley Street Arboretum Nottingham NG7 4DX Lead Inspector
Dee Shelvey Unannounced Inspection 17th February 2006 11:00 Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 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 Vernon Terrace Care Home DS0000002236.V282977.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 Adults 18-65. 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 Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Mount Vernon Terrace Care Home Address 23-25 Waverley Street Arboretum Nottingham NG7 4DX 0115 9784345 0115 9783822 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) Mr Ahmed Rashid Holmes Mr Ahmed Rashid Holmes Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th September 2005 Brief Description of the Service: Mount Vernon Terrace consists of two large houses in a Victorian terrace situated in a residential area of Nottingham City. The home is registered for up to 16 people with a mental disorder (excluding Dementia and Learning Disability). The premises occupy three floors (including a basement recreational area) and are not adapted to meet the needs of service users with mobility needs. There are no lifts, handrails, or specialist bathing facilities. There are ten single and three double bedrooms available. The new tramline stops directly outside the home and offers easy transport into the city centre. The home does not have a car park, and the parking restrictions in the area can make it difficult to visit the home by car. The home had undergone complete refurbishment and repair following a serious fire. The home was forced to close whilst the damage was repaired and had reopened in November 2005. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two and a half hours. The home had reopened in November and four of the previous service users had returned. Four new residents had been admitted. The focus of the inspection was on how the home had responded to requirements set at the inspection of 22/02/05 before the fire occurred. It was found that some requirements relating to specific service users were no longer relevant. The methods used were reading documents, examining records, discussions with the manager, speaking with one service user and a discussion with a visiting community psychiatric nurse. What the service does well: What has improved since the last inspection?
The building had been refurbished and therefore offered a good standard of accommodation. The CPN commented that the home was now bright and much lighter than previously. The care plans had improved and now contain indicators/early warning signs of possible deterioration of mental health. They also now contain clear instructions for staff on how to assist service users to reach their goals. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Prospective service users needs are assessed and they are given an opportunity to visit the home. EVIDENCE: Case files seen contained full needs assessments and the CPN spoken with said that her clients were always given the opportunity to visit and to speak with other service users before moving in. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 8 Service users assessed needs are reflected in care plans and they are able to retain optimum control of their lives. Consultation with service users needs to be improved upon. EVIDENCE: Two care plans were examined and both contained evidence of service user need being considered. The plans contained instructions for staff on how to assist residents to reach their goals and risk assessments were carried out as necessary. Service users had signed the plans as evidence of their involvement. The manager said that service users were not yet being consulted about all aspects of life in the home. There were plans to extend their involvement but these had been disrupted by the fire and the issue is now under consideration to involve them in recruitment of staff, revision of policies and all other aspects. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,16 and 17. Service users are able to develop a life style to suit them and are treated with respect by the staff. The food served is satisfactory and mealtimes are flexible. EVIDENCE: Most service users are able to access the community without accompanying staff and therefore decide for themselves what social pursuits to take up. If people need assistance it is given discretely and they are enabled to follow their own interests. The home has a large recreation area in the cellar. The service user spoken with was happy with his life style and said the food was “okay”. Service users care plans contained nutritional assessments and the record of food served show a variety of dishes on offer. During the inspection staff were seen to treat service users with respect. The CPN spoken with confirmed this view and said she thought residents were well cared for. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 and 21 Service users receive good personal and healthcare support. EVIDENCE: The care plans examined contained evidence of methods in use to meet service users physical and emotional health needs. The CPN spoken to confirmed that the residents she worked with were well cared for and she was always called in if someones health deteriorated. She also said that people had a good quality of life at the home and it was considered a valuable resource. The care plans examined contained very brief assessments of the service users capability to administer their own medication; it was really no more than a statement. The service user had not signed an agreement for the home to assume responsibility and the record did not give any indication of why the decision had been taken. One person did retain the responsibility for obtaining and administering his medication. The manager had raised the difficult issue of death and dying with some service users but the plans contained very little detail on how they would wish to be cared for in these circumstances. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 12 Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users views are listened to and acted upon. EVIDENCE: The home had a satisfactory complaints policy and procedure. No complaints had been received but the record of minor grumbles was seen and provided evidence of service users being taken seriously and resolutions found. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25 and 30. The home offers a good standard of accommodation. EVIDENCE: The communal areas of the home and the individual bedrooms seen were clean, well decorated and comfortably furnished. Where necessary hot water pipes and radiators were boxed in. The service user spoken with expressed satisfaction with his room and the home in general. There were some minor works still to be completed; in bedroom number one where an old shower needed to be removed or boxed in as in its present state it presents a potential health and safety risk. The laundry room floor must be provided with an impervious covering to ensure proper cleaning process and control of infection. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,34 and 35 The staff meet the service users needs. EVIDENCE: The staff at the home are all family members but each has a defined role and a job description. All the staff had received a satisfactory check from the criminal records bureaux but because they were family no references had been obtained. Staff training had stopped during the homes closure and the manager was in the process of auditing training needs in order to draw up a training programme. The CPN spoken with expressed satisfaction with the staffs knowledge of service users mental health needs. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41 and 42. The service users rights are safeguarded and their health and safety promoted. EVIDENCE: All the records seen were up to date and accurate. The service users and staff files contained all the information required by statute and were securely stored. All the fire safety equipment was tested at appropriate intervals and the staff and residents attended fire drills. The homes policies and procedures on health and safety were satisfactory as were policies on infection control and food hygiene. Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 3 X X X X 3 3 X Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 18 Yes 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 YA20 Regulation 12,17, schedule 3 23(2)(b) 23(2)(b) 17 schedule4 Requirement The records must state the reasons for considering a service user incapable of administering their own medication. The old shower in bedroom one must be removed or boxed in. Provide impervious flooring in the laundry. Obtain 2 satisfactory written references for all staff. This is outstanding from the inspection of 22/02/05 Timescale for action 17/04/06 2 3 4 YA24 YA30 YA34 30/04/06 30/04/06 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA8 Good Practice Recommendations Extend the involvement of service users in the running of the home: in future recruitment, revision of the policies on smoking, drugs and alcohol. Make a record of attendees at fire drills to ensure that everyone attends twice a year. 2 YA41 Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 19 Mount Vernon Terrace Care Home DS0000002236.V282977.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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