Inspection on 21/06/07 for Mountbatten Nursing Home

This inspection was carried out on 21st June 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 Nursing Home 17/10/06

Mountbatten Nursing Home 09/11/05

Mountbatten Nursing Home 04/05/05

Mountbatten Nursing Home 30/11/04

Mountbatten Nursing Home 14/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Mountbatten Nursing Home 82-84 Trull Road Taunton Somerset TA1 4QW Lead Inspector Gail Richardson Unannounced Inspection 22nd June 2007 09:40 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 Nursing Home DS0000003272.V336300.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. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountbatten Nursing Home Address 82-84 Trull Road Taunton Somerset TA1 4QW 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) 01823 333019 01823 334793 sarahcollard04@aol.com Mr Richard Derek Brice Mrs Sarah Katrina Collard Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, not less than 60 years, who require general nursing care Up to three places for personal care. Date of last inspection Brief Description of the Service: The Mountbatten Nursing Home was first registered in 1984. The home is registered for 27 persons over the age of 60 needing nursing care. The current provider has been registered since 2000 and has up-dated and invested in the fabric of the home. Mountbatten is an adapted Victorian building providing accommodation on four floors with a large sitting room and conservatory. Doors open onto well tended gardens. There is a call bell system and adequate numbers of assisted bathrooms. Nursing care is provided at all times and the home liaises with other health professionals to ensure service users specialist needs are met. Sarah Collard is the registered manager. She is an experienced nurse who is pro-active in directing the nursing care of service users. She is supported by an experienced and stable team of nurses, carers and support staff. The proprietors Mr and Mrs Brice are involved in the management of the home on a daily basis. The current range of fees is from £504.00 to £700.00. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 1 day (7 hours) on the 22nd June 2007 by inspector Gail Richardson. A tour of the home took place and all the bedrooms and communal areas were seen. There were 25 residents currently residing at the home. 23 residents were receiving nursing care and 2 residents were receiving personal care only. The inspectors spoke to 9 residents, 2 visitors and 9 members of staff, the Registered Manager and Mrs Brice were available throughout the inspection. The Registered Provider was also present at feedback at the close of inspection. All residents spoken to, and who were able, spoke of the staffs kindness and willingness to help, one resident said, “Nothing is too much trouble “.All residents spoken with stated that they were happy with the care the received. As part of this inspection the inspectors surveyed the opinions of a random selection of residents and their representatives, GP’s, District Nurses and Care Workers, 10 surveys were sent to service users and 9 responses were received, relatives returned 10 surveys to the inspector. The inspector spent time talking to residents, visitors and staff and observed that on the day of inspection, residents appeared relaxed and comfortable in all areas of the home. It was evident from this observation that the residents looked well cared for and attention to detail of personal care was seen. There is an established, well-trained staff team and surveys from staff stated they felt supported by the management of the home. Records relating to care including three care plans, staff files, finances and health and safety records were examined The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. What the service does well: Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 6 One visitor commented when asked what the home does well replied “Everything”. All surveys received and comments made, stated that the staff are very good, very dedicated and hardworking. It is clear from comments received from residents and visitors that the home makes every effort to support both the residents and their supporting relatives. One comment was “I couldn’t ask for more, they have my admiration and gratitude”. These comments were repeated in most comment cards received. The home is a large Victorian building, which has an ongoing maintenance programme to maintain the fabric and décor of the home. The home is clean and had no malodour with service users surveys confirming that this is always the case. The homes staff induction programme has been developed to incorporate the Skills for Care, Common Induction Standards. The records seen included a skills analysis and development of needs identified. The development of a good induction programme provides a well trained staff to ensure residents are well cared for. Staff training encompasses all the mandatory training requirements and some staff have undertaken POVA training. The level of staff completing the NVQ is very high at 96 , this percentage includes qualified staff. Staff training needs are identified through supervision and appraisal and the management of the home support staff financially to undertake further training. This support to staff training continues to be commendable. The management of service users with nursing interventions appears well managed with the supporting involvement of visiting healthcare professionals. The manager had a positive leadership style, which reflects on the staff who feel supported by the management of the home. Service users spoken with all confirmed that the quality, quantity and variety of food is always good, there was evidence that individual preferences are catered for. What has improved since the last inspection? Medication systems identified at previous inspection as not meeting the required standard have not all been addressed and medication systems within the home are all satisfactory. The home has purchased nursing hi/low beds for residents with nursing needs. Two residents without specialist beds have been risk assessed and beds are available when required. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 7 An ongoing maintenance programme is underway to address repairs needed both on the fabric of the building and the décor including carpets and new furniture. Specialist equipment has been purchased and includes pressure relieving chairs and a drug trolley. The home now has written protocols in place for the administration of all medications. These protocols are clearly written and regularly reviewed for changes. 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 Nursing Home DS0000003272.V336300.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 Mountbatten Nursing Home DS0000003272.V336300.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 4 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to be able to provide prospective residents and relatives with sufficient information in the format of brochures, the Service User Guide and Statement of Purpose for them to make an informed decision about the home. All prospective residents receive a pre admission assessment by the registered manager to ensure the home can meet the assessed needs identified. EVIDENCE: 8 Residents surveys received stated that all 8 had received a contract and all felt they had received enough information prior to admission, about the home to make an informed decision. One relative commented regarding information supplied about the home “The staff are very approachable and supportive”. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 10 Residents and relatives confirmed that they visited the home prior to admission. Each resident receives a pre admission assessment to ensure that the home can meet all assessed needs. A sample contract was examined and contained all relevant information. It was discussed with the provider that residents who have Social Services contracts do not have the homes terms and conditions in the same detail and this area may need to be reviewed. Mountbatten Nursing Home DS0000003272.V336300.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 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has a care plan, the assessed areas of need were reflected in this plan of care and the detail recorded ensures that staff can provide a good standard of care. The management of medications systems has improved and now meets the required standard. Staff were observed to treat service users with dignity and respect at all times and residents felt well cared for. EVIDENCE: The inspector case tracked 4 service users from pre-admission to care planning and included documents relating to medication, accidents and finances. One care plan provided details of end of life care given. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 12 The care plans seen were of a good standard and provided staff with the details of identified risks and made a plan of care to meet these risks. Some aspects of these care plans were of a particularly high standard, including psychological and social care plans, night care plans and plans relating to specific nursing interventions. These were written in a clear and concise manner, which was supported by a good underpinning knowledge of resident’s choices and needs. The inspector observed this care taking place and examined the records maintained relating to the specific nursing interventions. Residents and relatives were involved in monthly care plan reviews. A care plan was examined of a service user who had recently died. The plan of care had been regularly updated to meet the changing needs of the service user and all care given had been documented. When asked do you receive the care and support you need, 8 surveys said always and 1 said usually, all 9 responded that staff listen and act on what the residents say and all 9 felt they received the medical support they needed. 5 staff surveys received, confirmed that these staff were involved in care planning for residents. 3 surveys were received from visiting health professionals, all confirmed that the home communicates clearly and works in partnership with them. They felt that the management and staff take appropriate decisions when they can no longer manage the care needs of the residents. None had received any complaints about the home and all were satisfied with the overall care provided to service users within the home. One comment received was that there is “Always excellent care and communication”. A further comment stated that there was “Overall high quality care for each resident, their needs are paramount” One comment received said ”My relative is wonderfully looked after. There is a great caring homely atmosphere. It’s a pleasure to be there”. The management of the medication systems were satisfactory and requirements previously made had been met. There were no gaps in the Medication Administration Records and the systems in place for the storage of prescribed creams and self administered medications has been addressed. Each room has a lockable safe fitted and all creams in use were named and marked with expiry dates and safely stored in the lockable storage. The home has written protocols in place for the administration of all medications. Residents have the option to self medicate should they want to. Suitable documentation was in place in respect of these residents and medication was safely stored within their rooms. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 13 A homely remedy policy is in place with signed consent on agreed protocols by the relevant GP’s. All medications were stored safely and securely with systems in place for ordering and disposal. Mountbatten Nursing Home DS0000003272.V336300.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 good. This judgement has been made using available evidence including a visit to this service. There is a wide range of opportunities for social stimulation and residents are supported to join in with organised activities or pursue their own interests. The meals in the home are of a good quality and a wide range of choice is available. EVIDENCE: Resident’s surveys asked are there activities arranged by the home that you can take part in, 1-always, 3-usually, 3-sometimes, 2-blank. The inspector spent time talking with residents and observed residents reading newspapers and chatting to staff. The planned activities are advertised on a board in the lounge. The home is continuing to develop and use the personal history books to promote discussion on a one to one basis. No activities were seen at this inspection, however the inspector observed staff talking to residents in a social setting, staff are allocated from the duty rota from the care team to undertake activities each day. One resident stated that there were no strict routines in the home and that they were free to decide how and where they spent their time. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 15 Everyone who expressed an opinion stated that they have choice about all aspects of their care and are comfortable to request any particular preferences. Care plans evidenced preferences of activities and stated service users choices of what time to get up and go to bed. There are a variety of organised activities including entertainers, quizzes, bingo, arts and crafts, Church Services and social events. In the lounge there was a TV, radio, books, magazines and newspapers. One relative commented that they appreciated birthday cards made at the home and sent to them and another resident said that hey loved to listen to the keyboard. One relative commented that they had always appreciated being able to ring and speak to their relative at any time. On one occasion, the home arranged for a surprised telephone call, which had meant a great deal to both or them. This relative also confirmed that they were always contacted if there was any concern with an attention to detail. One comment made was that a resident was used to a weekly church service and although there was monthly Holy Communion a more regular service was missed. The home should ensure that each residents preferences are met as far as is practicable to do so. The care staff provide breakfast each morning, the main meal of the day is at lunchtime and there is a pleasant dining room arranged in the conservatory. The tables were nicely laid with a choice of condiments and drinks to have with their meals. There is a choice of meal at both lunch and teatime and one resident explained that cups of tea arrived regularly. They further explained that should you wish for anything you only needed to press the call bell. On the day of inspection lunch was a choice of fish pie, fish finders and chips, chicken curry or lasagne, desert was semolina and jam or ice cream. Tea was Cornish pasty, cheese salad, tomato soup or sandwiches, also available was fruit whip and ice cream. The inspector observed lunch being served both in the dining room and residents bedrooms and it appeared to be enjoyed by all. Service users who required assistance were helped in a dignified and discreet manner. Service users with specific dietary needs and preferences were catered for and contact with the Community Dietician is made as and when required. The inspector visited the kitchen and noted an good standard of hygiene with ongoing cleaning taking place. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 16 The head cook has recently taken the CIEH Level 2 in Nutrition and Special Diets. The Environmental Officer visited the home in July 2006 and the manager addressed all issues identified. Resident’s surveys asked if residents like the meals at the home, 4-always, 5usually. One relative confirmed that their resident always enjoyed the food, residents told the inspector that meals are plentiful and delicious. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 17 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 17 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and residents are confident that the homes management team would appropriately deal with any complaints or concerns. Policies, procedures and training are available to staff to ensure they have the knowledge to prevent service users from the risk of abuse EVIDENCE: The home has policies and procedures in respect of recognising and reporting abuse, making a complaint and whistle blowing, staff training in abuse awareness also takes place at induction and some staff have received POVA training. 6 staff confirmed that they had information about protecting vulnerable adults and how you report any concerns about poor care practice or allegations of abuse The registered manager explained that the home has not received any complaints. Residents told the inspector that they would be comfortable to approach the manager or a member of staff with any worries or concerns. Staff also confirmed that they were happy to approach the management with any concerns and would be confident that they would be dealt with promptly and appropriately. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 18 One relative confirmed that the complaints procedure is available within the service user guide. Residents surveys confirmed that if unhappy they would know who to talk too, 6-always, 3-usually. All 8 staff surveys received confirmed that they had received a Criminal Record Bureau Check and examination of recruitment files confirms that these check were undertaken before staff commenced employment. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 19 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 20 21 22 23 24 25 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a large building with some parts of the building suffering from wear and tear that would be typical of a building of similar age and usage. The gardens are attractively laid out and suitable for service users use. EVIDENCE: The home is an older building converted to provide accommodation on 4 floors and provide a spacious lounge and conservatory. There is a communal lounge and dining area, these are well furnished and decorated. Personal accommodation is located on each of the floors of the home and is accessible to people with all levels of mobility. Stairs and lift access is available to each floor. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 20 All bedrooms seen by the inspector were comfortably furnished and had been personalised to reflect the tastes of the individual resident. Residents are able to bring personal effects and small items of furniture with them when they move to the home, which gives rooms an individual homely feel. Various aids and adaptations have been put in place to assist service users to maintain their independence. Specialist pressure relieving cushions and mattresses were seen were there was an assessed need. All wheelchairs were seen to be clean and maintained. Toilet and bathing facilities are provided in sufficient numbers and were clean and odour free, building work has been undertaken to develop the access to the toilet in the lounge to promote further privacy and easier access. The home was clean and appeared fairly well maintained. One maintenance staff was seen working on the day of the inspection and it is clear that the home has an ongoing maintenance programme. On the day of inspection new carpets were being fitted to areas of the home and evidence of redecoration of rooms was noted. A delivery of new bedroom furniture had taken place the previous day and the wardrobe has not yet been fixed to the wall but will be undertaken before the room is occupied. One comment received said that the building can be confusing to visitors, however another comment made was that the home is constantly maintainedthe garden is a delight. 9 residents surveys confirmed that the home is always clean and fresh. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are adequate to meet the assessed needs of service users and staff training is promoted to support service users. The induction process for staff has been developed to meet the Skills for Care, Common Induction Standards. EVIDENCE: The inspector examined staff rotas for the week of the inspection and discussed with staff and service users their views on staffing levels. Both staff and service users were confident that staffing levels were adequate to meet the needs of the service users. On the day of inspection there was one qualified nurse and 5 care staff plus the registered manager. Also working were 2 cleaning staff, 3 kitchen staff and 1 administrative staff. One relative felt that an increase in client to staff ratio would improve the home, staff spoken with at inspection said that they were able to ask the registered manager if they felt staffing levels needed to be increased. The home does not have a formal dependency tool for assessing when staffing levels need to increase. However, the registered manager works regularly within the home as part of the staff team and uses this opportunity to measure the level of staffing required. The registered manager works on all shift Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 22 including night duty. Resident’s surveys asked if staff were available when you need them said, 5-always, 4-usually. The recruitment process within the home is adequate, the 2 staff files examined contained sufficient detail but did not yet contain a staff photograph, the registered manager will ensure this is done. It was also advised that the manager needed to develop the employment history details to contain dates of commencement and leaving. This will ensure that at interview, the registered manager can explore any gaps in previous employment and document the reasons for this. This is undertaken to protect the residents from the risk of abuse. 8 staff returned comment cards to CSCI, all 8 staff confirmed that they felt they had received adequate induction and supervision when they commenced their job. The registered manager has developed the induction process to include the Skills for Care Common Induction Standards. The records examined for the two most recently employed staff showed that a robust induction had been undertaken and had been developed to include a skills audit and a plan for identified training needs. All mandatory training for staff had been completed and a plan was in place for the following year. Extra training had been undertaken by the manager and staff in areas including advanced Cape Plan Training, Mental Capacity Act training and Dementia Care. The home benefits from a stable workforce with some staff being employed at the home for many years. The home actively promotes staff to undertake NVQ training, currently 96.6 of staff have completed NVQ training , this includes qualified staff. Further training is available from external sources and the provider of the home funds this. Domestic staff had access to data sheets and had received training in the use of the chemicals provided. All 8 staff confirmed that they were clear of what the service users needs were and also 7 staff were aware of the duties they must not undertake. The home employs a skill mix of staff to include an RMN. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 23 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 32 33 34 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed and benefits from the positive and proactive management style of the registered manager Systems are in place to ensure the health and safety of service users whilst encouraging and promoting independence. EVIDENCE: The registered manager of the home is Sarah Collard who has managed the home for several years. Discussions with the inspector confirmed that she has a clear understanding of the needs of the service users living at the home and Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 24 constantly strives to develop a team of staff to provide a high standard of care at all times. One staff commented that they felt able to confide in the manager with any problems which may arise, a further staff member commented that they felt the home was very well run and had no problems from the management or staff. One visiting health professional said that the manager is “always willing to discuss patient care with us and ask for advice if needed. She works all shifts and so knows what goes on through the whole 24 hours.” The manager was also described as “Exceptionally good” and “Wonderful”. The home undertakes regular audits of care but surveying the opinions of the residents and their families This was last done 2 months ago. Questionnaires received had complementary comments regarding the environment and care given and offered more suggestions for activities. There are established systems in place for dealing with service users finances. The inspector evidenced that each service users personal monies were stored in individual envelopes with a running total of deposits and withdrawals. All service users records are stored confidentially in line with the Data Protection Act. Seven staff stated on the comment cards supplied that they were receiving regular supervision. The records available supported this, however not all topic set out in the National Minimum Standards are included in the supervision sessions. The Registered Manager plans to review this process and incorporate supervision into induction and training records. Accident records were viewed and were seen to be reviewed and audited monthly for trends and regular occurrences and action taken to reduce any risks of further accidents taking place. Maintenance records were well maintained and up to date., these included ; * * * * * * * * * * Fire Extinguishers Hoist Servicing Emergency lighting PAT Tests Boiler servicing COSHH Hot water temperatures Wheelchair maintenance Electrical Hard Wiring Fire System DS0000003272.V336300.R01.S.doc Version 5.2 Page 25 Mountbatten Nursing Home * Lift servicing * Nurse call servicing * Accident audit. Eight staff surveys received stated that they were provided with protective clothing and necessary equipment to do their work safely and cleaning staff confirmed that they had access to COSHH data sheets and had received training in the safe use of chemicals. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 26 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 X 3 3 3 Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP18 OP7 OP29 Good Practice Recommendations The policies and procedures at the home are recommended to be reviewed on an annual basis and the required updates made. It is recommended that the risk assessments identified be reviewed annually or as changes occur and these be signed and dated. The registered manager is recommended to add to the application form, dates of changes of employment to ensure that employment history can be fully investigated and any gaps can be discussed and documented at interview. Photographs are also required for all staff files. Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Mountbatten Nursing Home DS0000003272.V336300.R01.S.doc Version 5.2 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. 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