Inspection on 07/07/05 for Mountfield

This inspection was carried out on 7th July 2005.

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

Mountfield 09/11/06

Mountfield 04/10/05

Mountfield 17/02/05

Mountfield 08/09/04

Mountfield 09/03/04

Similar services:

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Claremont House

Oak Ridge

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

CARE HOMES FOR OLDER PEOPLE Mountfield Millcroft Norwich Norfolk NR3 3LS Lead Inspector Ann Catterick Unannounced 7 July 2005 11:00 th 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 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. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mountfield Address Millcroft Norwich Norfolk NR3 3LS 01603 416201 01603 409621 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Norfolk County Council - Community Care Fiona Harley Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 39 Service Users who are Old People. Date of last inspection 17 February 2005 Brief Description of the Service: Mountfield is a care home providing personal care and accommodation for 39 older people and is owned by Norfolk County Council. Thirty-seven permanent placements and two respite care. The home stands in its own grounds in a residential area in the north of the city and is close to all local amenities. Mountfield is a purpose built local authority home that was first opened in 1975 and refurbished in 1996. The home is a two-storey building that is divided into 6 units. Each unit has its own lounge and separate dining area with kitchenette. There is also a communal lounge on each floor as well as a large conservatory, bar and shop area. There is a shaft lift giving access to the first floor. At the time of the inspection the home was offering a pilot for restaurant style meal times for those who chose to use the service. This has meant that the lounge near the kitchen has, on a temporary basis, been changed into a dining area. All service users have their own bedroom and two of the bedrooms could be shared if service users chose to do so. Several of the bedrooms are rather small. The home has ample bathing and toilet facilities. The gardens offer further communal space in the summer months. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place between 11am and 4pm on the 7th of July 2005. The Inspector was able to speak with the Manager, staff, service users and a relative as well as inspecting part of the building and joining service users for lunch. The Inspector was also able to look at written plans of care for service users and staff files. The inspector was satisfied with all information gathered and observations made at the inspection. All of the comments made by service users were positive and the overall quality of care was good. What the service does well: The manager is very clear that all services and care provided to the service users should have the service user as central. Service users rights, dignity and privacy are promoted and this ethos is promoted throughout the home. The home has recently begun to pilot a restaurant style dining room and the inspector was able to join service users for lunch. All of those service users spoken to spoke positively about meal times. Some chose not to use the new dining area and were able to have their meals in their rooms or in the dining areas on the units. All of those staff spoken to said that the staff worked well as a team and service users felt that staff were kind caring and well trained to do their job. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 Service users receive a written contract/statement of terms and conditions that informs them of the details of their placement. Service users have their needs assessed prior to being offered a placement within the care home. EVIDENCE: The contract of a recently admitted service user was seen and it included all of the information required including the cost of the placement and the number of the room to be accommodated. This contract had been signed by a relative acting on behalf of the service user. This is standard practice for all admissions. The file of a recently admitted service user was seen and this included assessments from the social worker involved and the health service detailing relevant information. Prior to admission the prospective service user was visited by the manager of the home who completed her own assessment. On the day of inspection relatives of the service user were spoken to and were satisfied that their relatives needs were being met. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 10 Care plans were seen and these included service user’s health, personal and social care needs thus providing carers with the information needed to meet the individual need. All of those service users spoken to felt that they were treated with respect and that their right to privacy was upheld. EVIDENCE: Norfolk County Council have recently devised a new care plan template and the home is now using this with all new service users. The opportunity to include all of the information needed within the care plan is made available within the new form. Some of the care plans seen had not been fully completed and further details were to be included. This was specifically noted in the area of social history. Discussion was had with the manager and it was felt that the new care plans would be more comprehensive and include more detailed information by the time of the next inspection. Several service users were spoken to and all felt that they were treated with dignity and that their privacy was respected. Those staff spoken to gave examples of how they worked in a way that promoted privacy, respected Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 10 dignity and offered choice. Some of the examples given were, ensuring doors were shut when service users were bathing or using toilet facilities, offering personal care in a way that ensured privacy, offering a choice of what service users preferred to wear, offering choice at meal times and ensuring service users got up and went to bed when the chose. The manager was clear that she felt that all services provided should be provided with the needs and preferences of the service user as paramount. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Following conversations with staff and service users it was judged that some of the more independent service users may not be having all of their social needs met. Friends and family are welcomed within the home and community contacts are encouraged. Service users receive a wholesome appealing balanced diet in pleasing surrounding at a time of their own choosing. EVIDENCE: It was commented upon by staff and some service users that those service users who are independent and did not need to be provided with much personal care did not have very much contact with staff as staff were always busy with those service users who had significant personal needs. Service users said that friends and family were always made welcome within the home and this was supported by comments made by visitors at the home on the day of inspection. The home has recently been asked to pilot a new scheme that offers a restaurant, cafeteria type service for all meals within a new dining area created Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 12 adjacent to the kitchen on the ground floor. Service users can, if they choose, also have their meals in their bedrooms or in their unit kitchens. Service users who ate in the restaurant area were spoken to and most spoke very positively about the new system. Cooked meals were offered three times a day every day and many service users were having regular cooked breakfasts as well as lunch and tea. Menus were provided on each table and people chose what they wanted to eat at the time of having the meal. The system was observed to be working very well with lots of positive feedback from service users. The menus were in small print and service users would benefit from the print being enlarged as some had difficulty reading it. Service users were seen at lunch time to be coming into the restaurant areas at different times between noon and 2pm giving them more choice as to when they ate their lunch. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a policy and procedure relating to complaints and this is made available to service users and their family and friends. Service users are protected from abuse by the homes policy and procedures and training is offered to staff. EVIDENCE: There had been no complaints since the last inspection. Details of the complaints procedures were seen in the entrance to the home, in the service user’s statement of terms and conditions and in Statement of Purpose and Service Users Guide. Those service users spoken to said that if they had any concerns they would be happy to speak to the manager about these and felt confident that their concerns would be listened to. Staff spoken to were clear about the whistle blowing policy and were confident that they would always refer to the manager or a senior member of staff if they had any concerns about the way service users were being cared for. Those staff spoken to who worked for the SSD had received training in this area. The member of agency staff working on the day of inspection said she did not recall any specific training in this area and it has been recommended that the manager ensure all staff working in the home have received or are waiting to receive training in this area. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 14 All service users spoken to said that the staff cared for them in a caring and kind way. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 All of those areas seen on the day of inspection were clean and tidy providing comfortable accommodation. EVIDENCE: Not all of the home was seen on the day of inspection but those areas seen included a lounge the new restaurant area and kitchen and all of these areas were clean and tidy free from any offensive odours. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 29 The home provides adequate amounts of staff on duty to meet the service users needs. All staff are trained to enable them to fulfil the roles and responsibilities of their job descriptions to ensure that service users are in safe hands at all times. The home offers robust recruitment and selection process although not all information gathered at the time of recruitment is available for the CSCI to inspect, within the home. EVIDENCE: During daytime hours the home provides 17hrs of care per service user per week and this appears to adequately meets the needs of service users. During the night only two night staff are on duty. The inspector was informed that when the work during the night is increased by the needs of service users at any specific time an additional member of staff is placed on night duty. The home has sufficient numbers of domestic staff and the home has always been found to be clean and tidy. Staff receive induction and foundation training and are encouraged to complete NVQ level 2 or above. Those service users spoken to felt that staff who cared for them were competent and well trained. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 17 Norfolk County Council has a recruitment and selection process that involves head office in the administration. There is some difficulty in evidencing whether or not this standard is fully met although the outcomes are met. Not all of the documents are kept within the home and therefore cannot be checked. An example of this is that references are kept at central and therefore cannot be seen. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32 and 35 The manager is competent and experienced and appears to be discharging her responsibilities in full. Service users financial interests are safeguarded. EVIDENCE: The manager, although relatively new to the post is promoting good practice and is establishing herself within her role. She has previous experience within the management role and is completing her NVQ in management. Those service users spoken to, spoke positively about her suggesting that she was very visible within the home. All service users have friends, family or financial advocates taking responsibility for their finances. The home has a secure facility for the storage Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 19 of some money for service users and records of transactions were seen and in good order. The manager is not appointee for any service users. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x 3 x x x Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 21 No 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 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 18 29 12 Good Practice Recommendations To ensure that agency staff have a clear understanding of the protection of vulverable adults policy. That all relevant information concerining recruitment and selection is made available in the home for inspection. That the manager look at ways of ensuring that those service users that are more independent are offered time with staff. Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 3rd Floor - Cavell House St Crispipns Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mountfield I55 s35557 Mountfield v223438 (un) 180505 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!