Inspection on 09/11/06 for Mountfield

This inspection was carried out on 9th November 2006.

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

The inspector 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 04/10/05

Mountfield 07/07/05

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 Mr Pearson Clarke Key Unannounced 9th November 2006 09:10 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 Mountfield DS0000035557.V319219.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. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountfield Address Millcroft Norwich Norfolk NR3 3LS 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) 01603 416201 01603 409621 www.norfolk.gov.uk Norfolk County Council-Community Care Fiona Marilyn Harley Care Home 39 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (38) of places Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One older person with dementia, who is named in the Commission`s records, may be accommodated. 4th October 2005 Date of last inspection 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. There are thirty-seven permanent placements and two respite care beds. 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 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. The ground floor lounge operates as a lounge dining area for the homes successful restaurant service. There is a shaft lift giving access to the first floor. At the time of this inspection the services maximum fee was £368.72 with each service users fee individually assessed according to individual circumstance. 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 DS0000035557.V319219.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers ,the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home and this report gives a brief overview of the service and current judgements for each outcome. What the service does well: What has improved since the last inspection? Although the service still needs to use agency staff to cover shifts it has reduced its reliance in this area and the manager has ensured that consistent staff from one agency are used. The arrangements for the storage of medication have been improved as has the system of delivery. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection of the service the homes manager has consulted with the registration authority concerning possible admissions which may have been at variance with the services registration. On these occasions a professional and reasoned approach was taken and during the site visit discussion with the manager confirmed a robust understanding of the need to make good admissions. Examination of sample service users records showed a thorough needs led assessment process to be in place and that the service provides the necessary information to enable service users to make an informed approach. The service does not offer intermediate care. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service had a good approach to care planning at the last inspection and the providers visiting reports have shown this to be being maintained during the year. During this site visit the inspector looked at six care plans and found them to be clear and well organised. The plans seen were structured in the same way, had been subject to review, containing necessary risk assessments and wherever possible to have involved the service user. The arrangements for the management of medication were inspected during the site visit. Medication is currently being moved into a new store although some of the stock items remain to be moved when extra storage units arrive. The new store has a modern fridge and is air conditioned to maintain optimum temperatures. Sample records were seen and were accurately completed. Part of the midday medication round was observed and no issues were identified. Discussion with Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 10 service users, management and staff confirmed an appropriate approach to the meeting of service users health care needs. This picture was backed up by service user plans and in line with the views of a visiting nurse the inspector spoke to. The inspector spoke to a variety of service users during his visit and it was clear that they felt very well cared for and that staff went to great lengths to promote and protect their privacy and dignity. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,12,14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector spent time observing life in the home and was also able to talk to a good number of service users and some visitors to the home. The picture painted was of a very good service, which operates with the best interests of those living there. Service users stressed that they felt the staff had time for them and that the home was relaxed and pleasant. There was a general view that the range of activity was broadly satisfactory, although this is an area that the inspector feel the service can continue to develop. People felt treated as individuals and the inspector observed staff working positively with people including a service user who was distressed being given individual support by a member of staff. The service encourages good contact with families and friends and regular newsletter helps foster a sense of community spirit. The home has an innovative approach to food based on a restaurant style of service. Feedback in relation to this was very positive and the inspector sampled lunch which was appetising and nutritious. Service Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 12 users enjoy a wide range of choice, including cooked breakfasts, vegetarian options, fresh fruit, salads and access to a cappuccino machine throughout the day. It was clear that the staff team as a whole work well to enable this to happen and the services cook is a passionate advocate for the approach adopted. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has no significant complaint history and inspection of the services complaints record at the site visit confirmed this. Service users spoken to were confident that they would be able to complain and be listened to if they needed to, and the provider has a thorough system in this respect. Discussion with the manager and inspection of training records showed that adult protection training for staff is part of the regular pattern of training and supports the homes policies and procedures in this area. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,25 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information submitted by the service prior to inspection indicated that consideration is being given to developing a specialist dementia unit within the home, however discussion during the visit confirmed that this idea has yet to develop. A tour of the building was undertaken and all areas seen were in good decorative order and the home was clean and fresh throughout. The home has a good range of attractive communal space both inside and out. Some service users rooms were seen and these were attractively decorated, colour coordinated and personalised. The home has a good range of bathroom and toilet provision suitable to meet the needs of service users. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 15 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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last inspection of the service found a generally satisfactory staffing situation in the home, although there was some concern regarding the excessive use of agency staff potentially impacting on the consistency of care. This issue was explored during the site visit and although agency is still having to be used to cover sickness etc the usage is much reduced. Furthermore the manager is only using one agency and has an arrangement to have consistent staff from them. The views of service users and their families indicated that the home is felt to have good quality staff who are well motivated and hard working. Observation and discussion with staff on the day of the site visit confirmed this picture. The provider has robust employment processes and sample tracking on the day indicated a sound approach. Training records seen by the inspector showed a good range of general and specialist provision and staff spoken to felt equipped to do their jobs. The service is well on the way to meeting government targets for NVQ level 2 qualified staff. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 16 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): 31,32,33,35 and 38 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information submitted by, and on going contact with the service management have indicated that the home has a strong and well organised management presence. This view was further reinforced as a result of the site visit. Observation on the day showed a strong sense of leadership to be in place and that service users and staff spoken to had trust in, and respected the homes manager. The service manager is experienced, qualified and demonstrated a commitment to improving the service in the interests of those living in the home. Records were well maintained and organised in an accessible way. Service users finances are robustly managed as evidenced by sample records Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 17 checked. The home has an annual development plan and an annual quality audit based on surveys of interested parties. Health and safety is well managed and the provider offers good support to its individual services in this area.. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x 3 x 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 x 3 x x 3 Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 19 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. Refer to Standard OP12 Good Practice Recommendations That the service continues to review and seek improvement in the provision of individual and group activity available to service users. Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Mountfield DS0000035557.V319219.R01.S.doc Version 5.2 Page 21 - 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!