Inspection on 03/01/06 for Mountearl House

This inspection was carried out on 3rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mountearl House 19/03/09

Mountearl House 29/12/07

Mountearl House 16/06/06

Mountearl House 04/08/05

Mountearl House 06/12/04

Mountearl House 09/08/04

Mountearl House 02/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Mountearl House 73 Leigham Court Road Streatham London SW16 2NR Lead Inspector Mary Magee Unannounced Inspection 3rd January 2006 10:00 Mountearl House DS0000022744.V276190.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 Mountearl House DS0000022744.V276190.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. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mountearl House Address 73 Leigham Court Road Streatham London SW16 2NR 0208-769-0322 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) The Robinia Group PLC Miss Aida Seferovic Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (10) of places Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Mountearl House is a large, listed building close to the centre of Streatham. It is home for ten adults. The home accomodates and provides care for people that have a learning disability as well as challenging behaviour and other mental health related issues. It is owned and managed by Robinia Care who manage several care homes for people with Learning Disabilities nationally. Local amenities are located within a short walking distance away as is local public transport. The house is divided into three main areas – ground floor, first floor, and annexe. There is no lift to the first floor and the home does not have CCTV cameras. There is a lounge on the ground floor of the main part of the building, used by all service users with a dining room and main kitchen located on the first floor. The annexe area of the premises has three bedsits as well as a separate lounge and kitchen. The home has a large garden to the rear of the property. Parking facilities are available to the front of the home. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for over seven hours. It took place during the day. The registered manager and deputy manager were present. Five support workers were spoken to individually. Four service users spoke to the inspector. A selection of records were viewed, these included the personnel records for staff and service users. A tour of the premises was conducted. It included all the communal areas as well as four service users’ bedrooms. What the service does well: What has improved since the last inspection? What they could do better: The staff team need to be more regularly supported and supervised. All staff require regular one to one supervision so that they know the code of practice Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 6 and the expectations of their role. This must also be used as an occasion to discuss individual performances and attitude. Improvements are needed in how senior managers undertake Adult Protection investigations into allegations. It is essential that senior management staff from the organisation delegated these responsibilities receive the necessary training and are competent in undertaking this task. Support staff at the home take responsible for completing health and safety checks but they are not aware of the importance of the role. They must understand the importance of raising repair requests and ensuring that these are responded to satisfactorily. Recommendations made by fire regulatory must be implemented within set timescales. While there have been some improvements in the recruitment procedures more development is required. Appropriate professional references must be available for all new staff before they begin work at the home. The home has demonstrated good practice and sought new enhanced disclosures for staff employed before POVA commenced. Areas of shortfalls identified during this exercise have been addressed positively by the organisation. A number of areas of the environment require attention. These include the carpets, furniture and bathrooms. Confirmation was seen that all these had been ordered and were due for delivery at the end of January 2006. 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. Mountearl House DS0000022744.V276190.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 Mountearl House DS0000022744.V276190.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): 12 Service users have confidence in the staff team, feel reassured and well supported. EVIDENCE: A new service users’ guide and an updated statement of purpose were available. They reflect recent changes within the organisation. Individual care plans have been developed with each service user. Care plans are detailed and contain good information on how to support individuals. A number of service users display challenging needs and have additional mental health issues. Restrictions are in place for service users to safeguard them. Such limitations for some service users include not accessing the community without the support of a staff member. For another service user a restriction had been agreed with his care manager. This was done so that he received the necessary support to manage his finances. Instead of him withdrawing a large sum of money at the cash point and misusing it on illegal substances staff allocate small amounts of cash daily as he requires it. They also support him to attend a community-based project five days a week. He does not have the opportunity or the access to some undesirable activities in the community as there is always a member of staff present with him. There were signs that good progress had been achieved. Direct observations made during the day provided evidence that staff were managing the challenging needs of individuals very well. Support workers were calm and reassuring with service users and help alleviate anxious situations. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 9 The staff team demonstrated a good knowledge of individuals care needs and how best to support them. A service user that is experiencing a difficult period was supported to attend the local mental health service. He spoke to the inspector of the rapid response of staff to his changing needs. He felt that staff listened to him carefully and gave him encouragement. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 10 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 78 9 The staff team demonstrate a good knowledge of individual service users’ care needs and know the correct procedure to adopt for service users that are aggressive or displaying challenging needs. Action is taken to minimise risk with additional support given to service users as necessary to avoid limiting the service user’s choice of activity. EVIDENCE: Care plans developed for service users are very clear and concise. They contain all the essential information including planned interventions and rehabilitation as well as individual goals. There were details of restrictions imposed and necessary. These included aspects relating to accessing the community solely and the vulnerability of service users. Members of staff were aware of the restrictions and of the importance of avoiding these for those at risk and especially with mental health related issues. Monitoring is done at night in the most discreet way possible to avoid disturbing service users but ensures that service users are safe. Regular service user meetings are held. Minutes from these meetings were viewed. Service users have individual bank accounts, records were viewed of Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 11 financial transactions and appeared accurate. It is recommended that these be audited as part of Regulation 26 visits to the home. The inspector was present when service users displayed some aggression and were quite challenging. Members of staff were competent and in control at dealing with the situations. They focused on positive aspects of behaviour with service users responding favourably to the procedures adopted. Service users have individual key workers. They are allocated from members of staff that relate and communicate well with service users. It was evident that service users preferences regarding key worker are listened to carefully and responded to positively. There are daily records maintained of progress as well as of any events that are relevant in their lives. Plans and risk assessments viewed had been reviewed in the last three months. Records indicated that internal reviews were conducted every six months. A number of local authorities remain outstanding. One area that requiring some more consistency are the end of month records made by key workers. It is recommended that these be written up every month so that all the information is easily accessible for the internal reviews. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 12 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): 11 13 14 16 Support staff play a key role in supporting service users to live fulfilling lifestyles. Improvements are needed to the choice of menus offered so that service users receive meals that take into account their dietary needs and preferences. EVIDENCE: Service users have the opportunity to develop and grow as individuals. Service users receive support and counselling including therapy as necessary and in accordance with plans of support. Indications were that service users capacities and abilities are considered and that they are supported to maintain and develop emotional and independent living skills. A service user experiencing frequent relapses in his mental health state responds well to the involvement of the manager in a time of crisis. On numerous occasions, she has supported him to hospital when he needs readmission. A number of service users frequent the local community. Examples seen include a service user receiving the necessary staff support to go out walking locally and visit the local hostelries. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 13 The staff team reflects the racial and cultural diversity of the service users and of the community in which it is located. Staff were seen interacting and engaging with service users. The service is flexible and responds as such when service users requiring support. During the day service users had not returned to college following the Christmas break. Members of staff were busy supporting them to attend a number of other activities in the community. A member of staff prepared a nourishing wholesome evening meal of chicken rice and vegetables. It smelt delicious and service users were enjoying it before the inspector left. It was observed from the fridge and freezer contents that many processed foods are used. Lunchtime daily includes sandwiches. Service users help themselves to breakfast daily. This consists of cereals and toasts. At weekends there is a cooked breakfast available. A number of staff felt that there was room for improvement in the quality of meals served. Menus are not planned. When shopping is done it is not reflective of what service users like enjoy or need but merely completed as a chore. A variety of vegetables reflecting cultural likes and preferences were seen. A dietician has been consulted and visited the home regarding the promotion of healthy eating and developing menus with service users that satisfied customers’ needs. Service users enjoyed a holiday in the autumn. An incident occurred that highlighted the lack of proper preparations for this holiday. The risk assessments were not completed satisfactorily. The holiday was booked to take into account individual needs but on arrival, the accommodation was not found to be satisfactory. A member of staff not too familiar with the service user was left to manage her single handed on occasions during the holiday. From discussions with staff and observing records it was evident that the group holiday was difficult to manage and that individuals would benefit from going solo with appropriate numbers of staff. The registered person must ensure that adequate and appropriate arrangements are made in preparation for service users’ holidays. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 14 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): 18 19 20 Personal support is consistent, reliable and responsive to individual service users changing needs. Service users with learning disabilities and mental health problems receive the emotional and psychological support from staff with the knowledge and understand of their needs. EVIDENCE: Routines at the home that include getting up and going to bed are flexible and in accordance with agreed planned daytime activities. Staff ensure consistency of and continuity of support by allocated key workers that service users help choose. Service users dress in clothing that reflects their personality and individuality. The staff team comprises of individuals from the same ethnic and cultural backgrounds as service users. Personal support is provided at the home by same gender carers where possible Service users receive the support to access health care appointments. The physical and emotional health care needs of service users are monitored closely. Prompt action is taken by staff to address any concerns that arise. Records of progress that include setbacks as well as relapses are dealt with appropriately. Instances of where the manager and members of staff supported service users at difficult times were seen. During the inspection a service user was supported to attend an emergency appointment with the Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 15 mental health clinic. On return, he had felt re- assured and was pleased with the outcome of the consultation. For another service user concerns were raised about his mental health following incidents in the community. Every effort was made by the staff team to achieve the best outcome for him. Recognising the importance of supporting a vulnerable person staff at the home led by the manager established good links with the probation service as well as with the mental health team. An appointment has been made for him to consult with a forensic psychiatrist. Health action plans are in place for service users. Records were up to date and gave an accurate picture of current conditions. Medication reviews are undertaken every three months. Senior trained members of staff administer medication. Medication is delivered in blister packs. A daily audit is undertaken of unblistered medication. There were no errors observed on the MAR sheets. Training in medication procedures has been provided for staff. A satisfactory report was available of an inspection undertaken recently by a pharmacist employed by PCT. Some areas recommended were the acknowledgement of medication received. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 16 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): 23 Staff have received training on safeguarding people from neglect or abuse. However not all senior staff within the organisation are knowledgeable on the Adult Protection Procedures. Copies of investigations into allegations of abuse or neglect are not always sent to the appropriate bodies. EVIDENCE: All the staff team have received training in the past year on protecting and safeguarding vulnerable people from abuse neglect or self-harm. An incident occurred some months ago while a service user was on holidays. It resulted in an allegation by a service user against a member of staff. A referral was made to the local authority. The authority recommended that the home investigate this allegation and send a report back on the investigation findings. Another home manager undertook the investigation. The allegations were not substantiated. Although the manager took all the appropriate steps and followed the local adult protection procedures, other areas need to be actioned by the home manager in the conclusion of the investigation. The inspector was informed of the incident initially but she had not received a report on the investigation or the outcome. The investigation has not been thorough. Despite staff receiving training recently in safeguarding adults from abuse or neglect a number of staff were not aware of the confidentiality issues relating to the investigations. Some members of staff felt that the manager should have told them the outcome of the investigation. More guidance and training is needed in this area for staff so that they are aware of the importance of confidentiality. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 17 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 27 28 30 The premises are a listed property and require a generous budget for maintenance. Some areas require more prompt attention so that it always offers a comfortable and homely and safe environment. EVIDENCE: Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 18 The home is located in a large detached house with an annex attached at the side. It is a listed building which means the upkeep is expensive. It is conveniently located for local amenities and public transport. There is a large enclosed garden to the rear of the property. It is suitable for the purpose offering spacious accommodation. The living accommodation is located on the ground and the first floor. The annexe area has three bed sits as well as a lounge and a separate kitchen. All the communal areas and three bedrooms were viewed. All were brightly decorated. The carpet in the communal areas of the annexe as well as in one bed-sit was stained and worn and needs replacing. A number of areas were identified as needing attention at the previous inspection and were the subject of requirements. The manager spoke of the progress made, the furniture and new baths had been ordered and selected. These are due to be replaced by end of February 05. This requirement is restated. New requirements were stated in respect of furniture that needs to be replaced. The furniture seen was of good quality but due to excessive wear and tear a number of drawers were missing from bedroom chest of drawers and from the kitchen in the annexe. There is a large leaded window on the landing. A number of the small panes of glass are cracked. The manager spoke of the difficulty experienced in getting the correct placement glass for this. Special shatterproof mirrors were available in a number of bedrooms. The home was clean and hygienic. Freezers and fridges were adequately maintained, temperatures were monitored daily. Since the unannounced inspection a visit by the environmental health officer was made unannounced. As a result a number of recommendations were made. The registered person must ensure that recommendations made by the environmental health officer are responded to within timescales set. Staff sleeping in facilities has been relocated to the ground floor at the request of the staff. Following a visit from LFEPA a recommendation was made regarding the supplying and fitting of a push bar device to the fire exit door. This recommendation had not been responded to. The room was stark in appearance and had no carpet. This room needs to be furnished appropriately to meet the needs of sleepover staff. The home has introduced a cleaning roster for staff. This has ensured that the premises are kept clean and hygienic. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 19 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): 32 34 35 36 Staff require more support and supervision to ensure that they adopt best practice in their roles. Positive steps have been taken to ensure that recruitment procedures for staff at the home are more thorough. The home responds swiftly to any irregularities found in staff personnel records. EVIDENCE: Service users receive support from staff who know their likes and dislikes, their preferred mode of communication and moving and handling techniques. Staff also knew how to manage extremes of challenging behaviour, they support emotionally service users that are experiencing mental health difficulties. A service user spoke of the vital and valuable help he received from staff as he coped with his deteriorating mental health. He said, “he could not have coped without the kindness and dedication of staff”. Eight members of staff have completed NVQ Level 2 –3 in care. Record keeping is good. Service user records are kept up to date. Care plans and assessments reflect accurately individuals’ needs and support requirements. A recommendation made about plans of care is for key worker sessions to be written up every month. Staff have participated in a range of training relevant to their role. Food hygiene, health and safety infection control are many of the topics covered this past year. All the staff team have participated in training. New staff have been engaged as part of the bank team. Bank staff have not had the same opportunity due to working on an ad hoc basis. It is essential Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 20 that bank staff are trained and supported to the same extent as the rest of the team. This is the subject of a requirement. Observations made and talking with service users evidenced that staff know how to encourage and support people that have short attention spans or that may be challenging. Interaction between staff and service users was good with staff engaging service users for a large majority of the time during the day. At the previous inspection some essential information was missing from staff files. Since then these gaps have been explored and essential information has been filed correctly. One new member of staff was recruited since the last inspection; she had two written references supplied as well as an enhanced disclosure from the Criminal Records bureau. There was no professional reference from a previous employer, there was no stamp to indicate authenticity. The home is currently applying for new CRB disclosure certificates that include POVA checks. These are to ensure that all necessary documentation is available for staff that were engaged before the POVA checks came into existence. The manager found discrepancies in staff details and documentation. The matter is currently under investigation. A decision was made to suspend the member of staff until all the issues were clarified. Another member of staff was found to have supplied fraudulent information. Disciplinary procedures were used. The registered manager should ensure that CSCI is kept informed of the outcome of the investigation into the inaccurate information available for suspended staff member. While staff display good practice with service users there are some care staff that require more supervision and support. Not all staff are cooperative and avail of one to one supervision. One support worker said that he had not attended one to supervision for over ten months. Records were seen of one to one supervision provided to staff. It showed that it was irregular and inconsistent. Regular team/group meetings are held. Minutes of these were viewed. They demonstrated that staff views were listened to and taken on board. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 21 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): 37 39 40 41 42 The home benefits from a manager that is experienced, interested and that wants the best outcome for service users. More attention is required to the maintenance of essential equipment supplied so that the environment is safe for service users and staff. EVIDENCE: The manager has been in post for two years and is currently completing her RMA. She is registered with CSCI as the manager. Recently she has benefited from the support of a newly appointed deputy manager. There were indications that this had been advantageous and assisted in managing the staff team more effectively. Team meetings are held regularly for staff. Minutes of these meetings were viewed. The inspector interviewed five members of staff individually. A number of those interviewed raised issues about what they considered as favouritism and that part time staff had the opportunity to work more hours than full time staff. While rotas for the bank holiday showed that some staff worked over forty hours there was no evidence to suggest that part time staff were treated Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 22 more favourably. In fact the reason that the part time staff worked such hours according to the manager was to ensure that full time staff did not work excessively long hours. The manager has become more assertive and with the support of the deputy manager addressed areas of poor practice with members of staff. From conversations with individual members of staff there were indications that some support staff were unwilling to cooperate with management. This area needs to be further addressed by the manager. Staff views should be listened to and considered to avoid staff focusing on issues that detract from caring for service users or from the aims and objectives of the home. If this is allowed to continue it will affect the morale of the team. The registered person should ensure that the registered manager promotes and maintains a good personal and professional relationship with staff. Policies and procedures were current. However as stated in the report senior staff appointed by the organisation involved in Adult protection investigations are not demonstrating the competencies necessary to undertake these investigations and require further training. The home has a quality assurance system in place. Regulation 26 visits as well internal reviews form part of the evaluation system in place. A copy of the development plan based on the outcome of the monitoring system was not available at the inspection. The registered person must ensure that a copy of the development plan for the home reflecting aims and outcomes for service users is forwarded to the inspector for evaluation. The organisation has taken steps to respond to requirements set at previous inspections. The Inspector examined three service user files. These contained recent and relevant information on service users. Handover records are good and give a good indication of all the events as they occur as well as any significant changes during the shift. The handover records are also used to keep check of petty cash as well as financial transactions for service users. Response time to repairs have improved. The manager spoke of the changes to the maintenance person, there have been further changes with another company due to get the contract. While the majority of the building is well maintained and health and safety audits are conducted for the premises there are areas that require more attention. A staff member spoke of her responsibility in checking that doors were closing properly and of ensuring that there were no obstructions to fire exits. It was recorded in a maintenance book that batteries were not operating in door closures but that no further action had been taken. The registered person must ensure that staff are competent in doing health and safety checks and taking the necessary action to respond to equipment that is not operating effectively. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 23 The maintenance book was unavailable as the handyman had taken it. As a result there was no evidence that emergency lights had been services for some time. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 24 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 3 2 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 2 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 x 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 2 3 1 x Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 25 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 17 Regulation 16 (2) i Requirement Timescale for action 30/03/06 2 YA23 37 (1) g 37 (2) 3 YA40YA23 13 (6) 4 YA23 13 (6) The registered person must provide in adequate quantities, suitable wholesome and nutritious food which is varied and properly prepared. Service users must be involved in devising the menus. (There has been some progress made towards meeting this with the involvement of a dietician, timescale of 30/10/05 extended) The registered person must 30/01/06 ensure that CSCI are kept informed without delay of the outcomes and final reports of any investigations into allegations of misconduct against a member of staff. The registered person must 28/02/06 ensure that organisational staff are aware of Adult Protection Policies and Procedures and that any investigations necessary as a result of allegations of abuse against members of staff are conducted thoroughly and appropriately. The registered person must 30/03/06 ensure that senior management staff appointed to undertake DS0000022744.V276190.R01.S.doc Version 5.1 Mountearl House Page 26 5 YA24 23 (2) h i 6 YA26 16 (2) c 7 YA27 23 (2) j 8 YA27 23 (2) b 9 YA28YA26Y 16 (2) c 10 YA28 23 (3) a 11 YA30 16 (2) j 12 YA35YA32 18 (1) c 13 YA34 19 (1) (2) (3) investigations into allegations of abuse are trained and competent in the role The registered person must ensure that the worn couches are recovered or replaced. (New furniture was on order) The registered person must ensure that stained and worn carpets in bedrooms and communal area of the annexe are replaced. The registered person must ensure that the bathrooms are refurbished and that chipped baths are replaced.( Not met within timescale 0f 30/10/05) The registered person must ensure that cracked glass on the landing window is replaced. (Not met within agreed timescales, extension agreed to enable home acquire replacement leaded glass) The registered person must ensure that that broken drawers in bedrooms and kitchen units are repaired or replaced The registered person must ensure that consideration is given to comfort for the staff that sleepover, a carpet is needed in the room used. The registered person must ensure that recommendations made by the environmental health officer are responded to within timescales set The registered person must ensure that bank staff are trained and supported to the same extent as the rest of the care staff and the team. The registered person must ensure that recruitment procedures are more rigorous. At least one of references supplied must be a professional one, DS0000022744.V276190.R01.S.doc 28/02/06 30/03/06 28/02/06 30/03/06 30/03/06 30/03/06 28/02/06 30/03/06 30/03/06 Mountearl House Version 5.1 Page 27 14 YA36 18 (2) 15 YA39 24 (2) 16 YA42 23 (4) 17 YA42 23 (4) a,b,c 18 YA42 23 (5) previous work histories to be explored fully. Documentation supplied must be examined closely photocopied and kept on personnel files. The registered person must ensure that staff are supervised and supported regularly and consistently. One to one supervision must be provided to each staff member staff at least six times a year. The registered person must ensure that a copy of the development plan for the home reflecting aims and outcomes for service users is forwarded to the inspector for evaluation. The registered person must ensure that staff are competent in undertaking health and safety checks and taking prompt and necessary action to respond to equipment that is not operating effectively. The registered person must ensure that emergency lights for the home are serviced. Confirmation that this is completed to be sent in writing to the inspector The registered person must ensure that all the recommendations made by the fire authority are responded to. 30/03/06 28/02/06 28/02/06 28/02/06 28/02/06 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 YA6 Good Practice Recommendations The registered person should ensure that end of month records that include key workers notes on service users DS0000022744.V276190.R01.S.doc Version 5.1 Page 28 Mountearl House 2 3 4 5 YA20 YA34 YA41YA7 YA37 are kept up to date. The registered person should ensure that for medication received into the home by blister pack that it is acknowledged MAR sheets. The registered manager should ensure that CSCI is kept informed of the outcome of the investigation into the inaccurate information available for one staff member. The registered person should ensure that service user bank accounts and financial transactions are audited as part of Regulation 26 visits to the home. The registered person should ensure that the registered manager promotes and maintains a good personal and professional relationship with staff. Mountearl House DS0000022744.V276190.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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