Inspection on 23/10/07 for Mountbatten Lodge

This inspection was carried out on 23rd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mountbatten Lodge 14/04/09

Mountbatten Lodge 17/04/08

Mountbatten Lodge 19/02/07

Mountbatten Lodge 20/01/06

Mountbatten Lodge 25/06/05

Mountbatten Lodge 14/01/05

Mountbatten Lodge 17/08/04

Mountbatten Lodge 26/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mountbatten Lodge Old Crabtree Lane Hemel Hempstead Hertfordshire HP2 4EX Lead Inspector Yoke-Lan Jackson Key Unannounced Inspection 23rd October 2007 11:00 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 Mountbatten Lodge DS0000019476.V353540.R02.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. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountbatten Lodge Address Old Crabtree Lane Hemel Hempstead Hertfordshire HP2 4EX 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) 01442 244188 01442 282546 www.quantumcare.co.uk Quantum Care Limited Mrs Roslyn Renimida Turton Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60) Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th February 2007 Brief Description of the Service: Mountbatten Lodge is situated in the Jarman Park Area of Hemel Hempstead, close to the town centre with its local shops and facilities and adjacent to a large supermarket and leisure park. Mountbatten Lodge is a purpose built home for up to sixty older people. The home is on two floors and divided into four individual units with single en-suite bedrooms, a lounge, dining room and assisted bath and shower rooms. Two units cater for people with dementia and these are on the ground floor with access to an enclosed garden area. Parking for cars is available. Currently the fees range from £400 to £550 per week. Information about the home and the services it offers are contained in its Statement of Purpose and Service Users Guide. A copy of these and the most recent CSCI inspection report should be available on request in the home. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on 23/10/2007. The registered manager was present. The home at the time of the inspection had 59 people in residence. The inspection began with a tour of the premises. Time was spent observing the lunchtime routine and how the staff interacted with the residents. Residents and staff were spoken to and documents were examined. The inspection ended with a detailed discussion with the managers. Information received by the Commission since the last inspection has also been reviewed. This includes the Annual Quality Assurance Assessment (AQAA) which providers of registered services are required to complete. The AQAA focuses on how well outcomes are being met for people using the service. What the service does well: What has improved since the last inspection? The standards of care and the management of the service continue to be maintained. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 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 Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 & 3. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Written information is available and prospective clients and their relatives are given the opportunity to visit and assess the facilities and suitability of the home. Prospective residents can be assured that a pre-admission assessment is carried out before they are admitted which ensures that the home can meet all their care needs. EVIDENCE: All the residents had been assessed prior to their admission. The admission files examined contained pre-admission information concerning the residents. On the day of the inspection, the deputy manager and a unit manager were out visiting a prospective client who is currently in hospital. Once assessed, the prospective client will be admitted into the home provided the pre-admission assessment shows that the home is able to meet all their care needs. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have access to healthcare services, and each resident has a written care plan so that staff know what care is required and how to deliver the care to meet individual needs. Medication is not always handled in accordance with legislation and the home’s own policy and procedures, which may put the safety of residents at risk. EVIDENCE: There are two units on the ground floor for residents with dementia. The first floor is for residential clients, some with physical disabilities. On the day of the inspection there were staff readily available to assist people. The residents were appropriately supervised in the communal areas. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 10 The care plans examined have detailed information on each resident’s healthcare and social needs. The home manager is reviewing all the care plans to ensure consistency in the filing process. Each resident is given access to healthcare and specialist services. Residents choose their own doctor. The management reports that there are about 20 fall incidents per month. The management is reviewing the fall incidents and hopes to reduce the figure by taking appropriate preventative measures. The management carries out random checks to ensure proper handling, storage and administration of medication. All controlled drugs are kept in the controlled drug cupboard in the storage room. All medicines that are in use in each unit are kept in a drug trolley that is usually kept in the medication storage room. On the day of the inspection the drug trolley was attached to the wall in each unit. The temperature in the unit needs to be monitored closely to ensure that the temperature is at or below 25 degrees centigrade if the medicine trolley is kept in the unit throughout the day. Some external cream was found in the same section as some medicines for internal use in one of the drug trolleys. Some gaps were found in the Medication Administration Record (MAR) charts that were not accounted for. The home manager agreed that contemporaneous notes should be written at the back of the MAR charts. She is planning a medication training session for staff to ensure that medicines are handled and administered in accordance with legislation and the home’s medication policies and procedures. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to exercise control over their lives and to maintain contact with their families and friends. The activities provided are varied and flexible to suit the lifestyles of residents. The meals are wholesome and nutritious to meet the needs of the residents. EVIDENCE: Residents spoken with were quite content with the organised activities by staff. The manager said that there is a group activity each day. However, on the day of the inspection, there was no activity observed. The activity co-ordinator was off on the day and a visiting entertainer due to provide a pet therapy session was unwell and therefore the session was cancelled. However, care staff were seen giving one-to-one attention to residents. There is a diary kept of the daily activities and the names of residents who were involved. It was noted that lunchtime was unhurried and there were staff readily available to give assistance to individuals. Residents spoken with said that they are quite happy with the meals provided. They said that there is always a hot Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 12 meal and alternative dishes. Comments received included “Its quite good” and “There is plenty to eat.” Residents are given choices daily. Healthy eating is encouraged. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 13 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): Standards 16, 17 & 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a robust Complaints Policy and Procedure in place so that residents are listened to and action is taken, and their legal rights are protected. EVIDENCE: The management investigates any complaints or concerns raised by residents, relatives and others. Immediate action is taken to resolve any issues raised. Staff have training on issues concerned with the safeguarding of vulnerable adults. They are aware of the Whistle-Blowing Policy. The home follows the multi-agency Safeguarding Procedure of Hertfordshire County Council. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 14 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): Standards 19, 22, 23, 24, 25 & 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and homely place with access to all the communal facilities and the specialist equipment they require to maximise their independence. EVIDENCE: Residents are in a safe environment in spite of the redecoration that is being carried out on the first floor. The management hopes that all the redecoration will be completed before Christmas. The surrounding grounds are well maintained and the entrance to the main building is well decorated with hanging baskets of flowering plants. The bushes will be cleared around the fish pond to make room for more seating for the residents and visitors in the summer months. All doors are held open with automatic hold-open door devices. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 15 Residents have the specialist equipment they require to maximise their independence. There are sufficient hoists in each unit although one hoist is broken and is waiting to be repaired. The home appeared clean and tidy on the day of the inspection. The domestic staff were seen cleaning the bedrooms. Personal items were on display in each bedroom examined. Residents spoken to seemed pleased with their bedrooms. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 16 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): Standards 27, 28, 29 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported and safeguarded by the robust recruitment policy and practices in place. There is an effective staff team, with sufficient numbers on duty to ensure that the care needs of the residents are met appropriately. EVIDENCE: On the day of the inspection, the residents spoken with gave positive feedback about the staff. Comments included: “The staff are helpful” and “I am quite satisfied with the care.” It was noted during the inspection that there were staff readily available to assist the residents. The home has recruited a number of care workers since the last inspection. The recruitment procedure is in accordance with legislation. The staff files examined were all kept up to date. There is a 4 weeks induction programme for all new recruits. All new staff only start work after police checks and clearance including clearance from the Protection of Vulnerable Adults (POVA) list. There is a rolling training programme for all staff. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 17 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): Standards 31, 32, 33, 35, 36 & 38. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and this benefits the residents, whose health, safety and welfare are promoted and protected. EVIDENCE: The standards of care and service are well maintained. Residents seemed content and pleased with the care given. Staff are regularly supervised. All equipment-servicing records are kept up to date. The financial records kept for the personal allowances for each resident are kept up to date and random checks made on the day of the inspection showed that the records agreed with the money available. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 18 Although there are some shortfalls in the handling of medication, the management is working towards improving staff training to ensure staff adhere to the home’s medication policy and procedures. The home has a current Liability Insurance Certificate and the CSCI Registration Certificate was on display. The quality monitoring system includes written survey questionnaires. An annual report is readily available for inspection. The recently introduced CSCI Annual Quality Assurance Assessment (AQAA) form, issued to the home for this inspection, was returned on time for this inspection. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 19 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 18 3 3 X X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 3 Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement To ensure the safety of the residents all medicines in the home must be handled in accordance with the Medicine Act 1968, Guidelines from the Royal Pharmaceutical Society and the requirements of the Misused of Drugs Act 1971. Therefore: 1. All medicines for external use must be stored separately from those for internal use. 2. All gaps on the Medication Administration Record charts must be accounted for by way of contemporaneous notes at the back of the MAR charts. 3. The temperature of the storage area for the drug trolley in each unit must be monitored to ensure it is at or below 25 degrees centigrade. Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 21 Timescale for action 23/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mountbatten Lodge DS0000019476.V353540.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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