Inspection on 29/08/06 for Mountfield House

This inspection was carried out on 29th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mountfield House 12/02/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Mountfield House 286 Penn Road Penn Wolverhampton West Midlands WV4 4AD Lead Inspector Mr Ian Harris Key Unannounced Inspection 29th August 2006 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mountfield House DS0000066683.V309617.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 House DS0000066683.V309617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountfield House Address 286 Penn Road Penn Wolverhampton West Midlands WV4 4AD 01902 330017 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) Mrs Sandra Middleton Mr Gary Middleton Mrs Inderjit Kaur Kular Care Home 14 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (14) of places Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of Older People is 14 of which 3 Older People can have mild dementia. 24th July 2006 Date of last inspection Brief Description of the Service: Mountfield is a large Victorian building, which has been adapted to meet the needs of fourteen older people who are accommodated in fourteen single bedrooms. Bedrooms are located on both ground and first floors and communal areas are situated on the ground floor. Bathing and toilet facilities are located throughout the home and all floors are accessible by a passenger lift for those with mobility difficulties. There is a dining room, a large lounge and a smaller lounge on the ground floor, which at present is also used by night staff for sleeping in purposes. The home do not have a staff room and/or a suitable accommodation for sleeping in for night staff. The home is situated near to a full range of amenities, which includes shops, a public house, a library and places of worship. The home is on a direct bus route into Wolverhampton city centre. Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 5. hours commencing at 8 a.m. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 2 members of staff and 6 residents were spoken to. It was noted that the fees range between, £336 to £394. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. All the residents spoken to who could express themselves in a meaning full way expressed their satisfaction with the home and the care they receive. “ We are all very happy here it’s like a hotel” “ We have good food and the home is always nice and clean” “ The staff look after us very well ” were some of the comments made. What the service does well: What has improved since the last inspection? Considerable amount of work has taken place to improve the home and the quality of the service provided. They include the redecoration of the first floor corridors, two bedrooms the office and storeroom. New floor covering has been fitted to the ground floor corridors and two bedrooms. Also a new hot water and heating system has been installed and all hot water outlets has been fitted with new mixer valves. Work was in progress to redecorate the kitchen. Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 6 Planning permission has been submitted to the council to build a conservatory at the rear of the building which will provide extra lounge space and a staff room. 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 House DS0000066683.V309617.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 House DS0000066683.V309617.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The home has a satisfactory admissions procedure ensuring the individual needs of the residents are fully met. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: All the residents who are funded by the Local Authority undergo a full multidisciplinary assessment prior to admission. The residents’ who are self funding are assessed by the Care Manager, using the homes assessment forms. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The six care plans inspected contained pre admission assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. Mountfield House DS0000066683.V309617.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): &, 8, 9, and 10 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication in not good and residents could be at risk. The quality outcome in this area is poor. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Six residents case files were inspected and all contained a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the Care Plans are being carried out and reviewed on a monthly basis. Medication is administered by means of a monitored dosage system. However Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 10 this system is not being used properly. Drugs are being transferred from the Dosset boxes into a pots and taken to the resident. This is secondary dispensing and must stop. It was also obsevered Staff were giving out the drugs to all the residents’ and then filing in the record sheets in the office. The record sheet should be filled in at the point when the resident takes or refuses medication. It was note that the drugs are stored in a cupboard in the small lounge. The provision of a drugs trolley that can be stored in the office and used to take the drugs to the resident would be a great improvement. All residents have single rooms. No personal care interventions take place in communal areas. Observed practice on the day of inspection was appropriate and showed respect for the residents. Consultation with health care and social care professionals is carried out within the resident’s bedrooms. Visitors are able to meet residents in their bedrooms or the small lounge on the ground floor offers that privacy when not being used Mountfield House DS0000066683.V309617.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 The home provides a stimulating experience for the residents where they are encouraged to maintain their independence as much as possible The home provides a good range of social activities within and outside the home designed to the capabilities of the residents The meals in the home are good offering both choice and variety and also catering for special dietary needs The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The routines and activities within the home are flexible and are built around the needs of the residents. There was also evidence to show staff consult with the residents regarding the choice of meals and activities within the home, at residents meetings. For residents with communication problem this is done by the key-worker. The key-worker also identifies interests that the residents wish to pursue. There is a regular programme of musical entertainment, boardgames, keep fit and sing-a-longs is organised within the home. There is a designated member of staff who has responsibility for organising social activities. In regards to outings there has been a canal boat trip and a trip to Blackpool this summer. The resident spoken to stated that both days were Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 12 lovely and they look forward to the next outing asked about the Blackpool trip they stated that they had chosen to go there. The observations made, examination of menus and the comments received from the residents and the relative’s representative confirmed that particular attention is given to the residents’ individual preferences. Comments made by residents regarding the quality, quantity and variety of food provided were highly complimentary. One resident said “it is like a hotel here”. Mountfield House DS0000066683.V309617.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies regarding protection from abuse, which includes a whistle blowing policy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home has a comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide that is place on the notice board in the hall. The home has a complaints book in which all complaints are recorded. It was noted that the Commission had received two anonymous complaints since the last full inspection. After investigation they were found to be un-founded. The home has not received any formal complaints since the last inspection all minor complaints are dealt with appropriately and quickly. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a new WhistleBlowing policy. These issues are also covered in the N.V.Q. training, which all the Care Staff is undergoing or have completed. There have been no incidents that have needed to be recorded or reported. Mountfield House DS0000066683.V309617.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The general standard of the environment is good providing service users with a homely, comfortable and safe place to live. The good standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. The quality outcome in this area is adequate. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home is long established and has undergone alterations over the years in order to provide appropriate accommodation for older people. The home is maintained to a good standard, as are, the gardens and grounds and provides a comfortable homely and safe atmosphere. It was noted that considerable amount of work has taken place to improve the home and the quality of the service provided. They include the redecoration of the first floor corridors, two bedrooms the office and storeroom. New floor covering has been fitted to the ground floor corridors and two bedrooms. Also a new hot water and heating system has been installed and all hot water outlets has been fitted with new mixer valves. Work was in progress to redecorate the kitchen. The residents Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 15 bedrooms have been personalised with the residents’ own personal possessions. This gives the appearance of a very comfortable environment. However the home does not provide a staff room and changing facilities. The home is in compliance with the Fire Safety Officer’s requirements. During the inspection, the home was found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control. The Registered Provider stated that the majority of staff has received training in infection control and they are made aware of the dangers of cross-infection. Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The home is well staffed with adequate numbers and skill mix of staff to meet the needs of the residents. The staff have a very good understanding of the resident’s support needs. The home has good policies and procedures regarding the recruitment of staff. There is a good training programme in place that ensures staff are competent to do their job. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The inspection of staff rotas and discussions with residents and relatives all indicated that the home is well staffed by caring competent staff. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. The home operates an efficient recruitment procedure and is registered with the Criminal Records Bureau in order to complete the appropriate checks on staff. There was evidence within the home that all the checks are being carried out. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a programme of N.V.Q. training has now exceeded the minimum standard. Also the care staff have attended Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 17 courses on Safe handling of medication, Risk assessment, Dementia care, and Moving and lifting, First Aid, and Fire Prevention. Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 The home is well managed, where service users interests and welfare is promoted. The home is operating a good system to assist residents with the safe handling and keeping of their personal finances. All the general records that were inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The Care Manager is qualified in both practice and management and has considerable experience in caring for older people in residential homes There are clear lines of accountability within the home and is very supportive of both staff and residents. Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 19 Observations made and discussions with residents and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager or staff with any problems they might have. The home has an internal quality assurance system in place to monitor the quality of the service. There is evidence that staff and residents meetings and staff supervision takes place. Two staff members confirmed that they are well supported by the Care Manager and proprietor. All of the records and administrative procedures within the home that was, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All safety equipment is check and well maintained. Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement The register person must ensure that secondary dispensing of medication is stopped and the monitored dosage system of administration of drug is used properly. The registered person must provide a staff room and changing facilities. The registered person must ensure that the Kitchen and toilet 12 are redecorated. Timescale for action 01/09/06 2 3 OP19 OP19 18 (3) (a) 23 01/12/06 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mountfield House DS0000066683.V309617.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 House DS0000066683.V309617.R01.S.doc Version 5.2 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. 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