Inspection on 15/01/07 for Mountside Residential Home

This inspection was carried out on 15th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mountside Residential Home 10/12/08

Mountside Residential Home 15/12/05

Mountside Residential Home 02/08/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Mountside Residential Home 9-11 Laton Road Hastings East Sussex TN34 2ES Lead Inspector Lucy Green Key Unannounced Inspection 09:45 15th January 2007 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 Mountside Residential Home DS0000064443.V304789.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. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountside Residential Home Address 9-11 Laton Road Hastings East Sussex TN34 2ES 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) 01323 646548 mountside2@aol.com Downlands Care Limited Mrs Freda Steuart-Pownall Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is fortythree (43) Service users must be aged sixty-five (65) and over on admission Date of last inspection 15th December 2005 Brief Description of the Service: Mountside is registered to accommodate forty-three older people. The property is situated in a residential area on the outskirts of Hastings, within close proximity to Alexandra park. The location of the home provides easy access to Hastings town centre and public transport links. Resident accommodation is provided on three floors, to which level access is provided by way of two passenger lifts, stair lifts and a series of ramps. Mountside is registered for thirty-three single bedrooms and five double rooms, however all rooms are available as single occupancy only, unless a resident makes an express wish to share. Communal facilities include a range of pleasantly furnished lounges and a large dining room. The home also boasts extensive award winning gardens to the front and rear of the property. Parking is available at the front of the home. Information provided by the Manager details that the current range of fees at Mountside is between £322 and £520 per week. Additional charges are payable for hairdressing, toiletries, chiropody and newspapers. More detailed information about the services provided at Mountside can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents, along with the latest CSCI inspection reports can be obtained directly from the home. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Mountside are referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from representatives and an unannounced site visit which lasted eight and a half hours on Monday 15 January 2007 between the hours of 09:45am and 6:15pm. The site visit included a tour of the premises and an examination of medication, care and staffing records. The Inspector sampled the lunchtime meal. Throughout the inspection process, the Inspector spoke with eight residents and two visitors individually and observed the way other residents spent time in communal areas. In addition feedback questionnaires were received from seven residents. Comment cards were sent to a number of General Practitioners who are connected with the home and comment cards were also sent to the Manager to pass onto relatives and visitors. At the time of writing this report eleven comment cards had been returned by relatives and visitors and two from General Practitioners. The Inspector spoke with the Registered Manager and interviewed five staff members, including two Senior Carers and three Carers. The Deputy Cook and Kitchen Assistant were also met with during the inspection process. What the service does well: Mountside provides a high quality service to the people it accommodates. The home has a relaxed and friendly environment where people are supported to live their lives as they choose. The feedback from one relative stated that “my mother has lived at Mountside for over two years. Her overall condition and physical ability has improved”. The Manager is a skilled and experienced practitioner who is completely dedicated to ensuring residents receive a high standard of care. She makes it her priority to know each of the residents and their needs personally. The home has an experienced team of staff who are committed to their work and have a good understanding of the needs of the people living at the home. Residents spoke highly of the support received by staff and positive relationships between staff and residents were observed. Feedback from Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 6 relatives and visitors echoed the compliments about staff and the home; “In my opinion Mountside are most excellent care providers. The entire staff have obviously been selected for their kindness and competence”. Meals are of also of a high quality with choice available at each mealtime. The Inspector sampled the lunchtime meal which was well presented and delicious. What has improved since the last inspection? What they could do better: A number of changes have occurred at Mountside over the last twelve months and whilst the quality of care provided is still good, the changes have not gone unnoticed. One relative commented; “the quality of service is the same, but something has changed” and another stated; “although we are happy with on the whole with our relative’s care, it is definitely not the same in general in the home lately”. One of the issues that the Registered Providers are requested to look at is the management structure of the home. The two deputy posts have been replaced by three Senior Carers and whilst those individuals in these roles are excellent carers, they do not have the management experience to run the home in the Manager’s absence. Feedback from all parties suggested that the quality and frequency of activities is not as good as at previous inspections. Whilst residents do have the opportunity to participate in meaningful activities, the consensus of opinion is that the previously very high standard in this area has fallen. The lack of management time available has led to the ongoing requirement that care plans and risk assessments are more detailed. It is important that knowledge and information is recorded in order to ensure consistent care approaches. The way medication is currently managed needs to be reviewed to ensure that residents are fully protected. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 7 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. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from an assessment process that ensures their needs are identified and confirmed they can be met before moving into the home. Mountside does not provide intermediate care. EVIDENCE: The Inspector viewed the pre-admission assessments for three residents who have moved to Mountside in the last twelve months. For all three residents, there was evidence that the Manager had conducted a thorough assessment on each individual prior to the resident moving to Mountside. Information from other relevant parties had also been obtained, including where appropriate the latest social care assessment and for those being admitted from hospital, a link letter or discharge form. A review of the subsequent care plans in place for these three individuals provided evidence that the information gathered that the assessment stage is then subsequently used to develop a plan of care. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 10 Those residents spoken with as part of the inspection process confirmed that either they or their representatives had had the opportunity to visit the home prior to moving in. All residents who met with the Inspector confirmed that they had settled in well at Mountside and that their needs are met by the home. The Registered Manager confirmed that Mountside still does not provide intermediate care. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff practice reflects a good understanding of residents’ personal and healthcare needs. Whilst the staff team have the knowledge, skills and leadership support to meet the needs of the residents, the documentation in place however, does not fully reflect the high level of care provided. Medicines would be managed more safely if the same person undertakes the dispensing and administration of medication. EVIDENCE: Staff practices observed throughout the inspection demonstrated a good understanding of the residents and their needs. Discussion with the Registered Manager and staff produced evidence that staff have the knowledge required to provide appropriate personal and healthcare support to the residents at Mountside. A sample of five care plans were viewed and whilst key information about residents’ needs is recorded, it was identified that the positive outcomes observed for residents at this time are still dependent upon staff knowledge and memories, rather than full and detailed recording systems. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 12 Risk assessments also require additional detail as four of the five care plans viewed did not contain individual risk assessments. It is required that where risks are identified, they are followed through with an assessment of the controls in place to minimise those risks. It is important that care plans are clearly linked to appropriate risk assessments and where necessary, management strategies. The quality in this outcome area has been rated as ‘good’ at this inspection as the consensus of feedback from residents was that their needs are being met at this time. Those spoken with commented “staff are very good, they give the right amount of support and are friendly and helpful” and “I get the help I need”. It has therefore been judged that the stability and dedication of the Manager and her staff team have prevented the lack of updated and comprehensive care planning from having a negative impact on the residents at Mountside. It was however discussed with the Manager that improvements to documentation must be made or there is a real risk that the quality of care could drop if there are changes to the management or staffing structure. The Inspector spoke with a Senior Carer about the procedures in place for managing medication within the home. It was identified that whilst staff have a good knowledge about the medication that is administered to residents, the practices currently adopted for dispensing and administrating medicines is open to error. As such, the home’s system at the time of the inspection involved one Carer dispensing all medication that was not in ‘blister packs’ into named pots. At the time medication is due to be administered, another Carer collects the relevant ‘blister packs’ and pots and administers to the resident, after which this individual signs the Medication Administration Record (MAR). The above system is not acceptable as the individual signing the MAR sheet may not be the person who has dispensed all of the medication they have signed for. Therefore, the accuracy of the right person receiving the right medication is down to the staff member knowing what tablets should be in the pot. This was discussed with the Manager and a requirement has been made that this practice cease and that correct procedures are implemented as a matter of priority. The medication listed on the MAR sheet was cross-referenced with the medicines stored in the cupboard and it was identified that some medicines for three residents were not available. The pharmacy had been contacted and new supplies were delivered during the inspection, but in future the home needs to ensure that they do not ‘run out’ of prescribed medication. One resident’s tablets were found loose in their individual named drawer within the medication cupboard and it was highlighted by the Inspector that all medicines must be stored in their original packets with the dispensing label. The MAR charts indicated that three residents administer their own medication and a Senior Carer confirmed that these medicines were kept in the Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 13 individuals’ bedrooms within a lockable facility. It was recorded in care plans that these people managed their own medication, but it was not possible to find evidence of the appropriate risk assessment or review in respect of this. For those residents whose medication is held by the home, it is recommended that consent forms are in place to evidence that the resident accepts that their medicines are stored by the home. A Senior Carer informed the Inspector that the home does not currently hold any controlled medication, however demonstrated that the correct systems for storage, recording and witnessing were in place if this situation were to change. The Manager informed the Inspector that staff who handle medication have completed relevant training and competency checks. All residents and visitors spoken with confirmed that the staff at Mountside are respectful and respect their right to privacy and dignity. During the inspection, it was observed that staff spoke appropriately to residents knocked on bedroom and bathroom doors before entering. Some residents have private telephone facilities in their bedrooms and for those that don’t, a payphone is available in the downstairs hallway. The home also has an internal post-box and mail is checked twice daily. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead their lives how they choose. Residents benefit from an inclusive environment where there are opportunities to participate in a range of activities. Residents spoken with were complimentary about the range of varied and balanced meals they receive. EVIDENCE: The daily running of the home was observed to allow residents the freedom of choice about when they get up and where and how to spend their time. Conversations with residents highlighted that they have each developed their own individual routines and wherever possible, staff facilitate this. The home arranges a number of in-house activities, including; a monthly church service, music afternoons, clothes sales, bingo and games afternoons. A motivation and exercise class is also held on a monthly basis. Some residents attend local community and church clubs. Whilst the provision of activities at Mountside has been judged as good, the inspector received feedback from a variety of sources that the standard and frequency of activities was not as high or as frequent than at the last inspection. This is a Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 15 pity, because the last inspection report rated activities as exceeding the National Minimum Standards. Many of the comments received expressed dissatisfaction at the decision to reduce the frequency of the motivation and exercise class from fortnightly to monthly. One resident informed the Inspector; “activities are not as good as they were, lots of gaps in the timetable now, whereas before there was something on every afternoon”. Feedback from a relative also commented; “additional activities to occupy the residents would be welcomed”. Other comments made to the Inspector included “it would be nice to see a vehicle for people to be able to get out in”. It is therefore recommended that the home consult with residents about the range of activities to ensure that people’s social and recreational needs and expectations are being fully met. Residents are encouraged and supported to maintain contact with their family and friends. The home operates an open door policy and residents are able to spend time with their guests in their rooms or in one of the lounges. Visitors were observed being welcomed into the home during the inspection. The Inspector spoke with two visitors who both spoke highly of the home and said they were always made to feel welcome. Written feedback provided by one relative stated; “I am always made welcome and make a point of going to fetes and the Christmas party”. With prior arrangement and a small cost, visitors are able to join their relatives/friends for a meal at the home. The provision of meals continues to be of high quality. Meals are prepared according to a rotating menu, with all parties confirming that an alternative is always available. Breakfast is served in bedrooms at a time agreed with the residents. Staff and residents confirmed that residents have a wide choice at breakfast, including a cooked option. Whilst lunch and dinner times are set, those spoken with all stated they liked to know what time to expect their meals. The Inspector sampled the lunchtime meal and enjoyed chicken and ham pie with fresh vegetables, potatoes and gravy. The other meal option was spaghetti bolognaise. The food was well presented, nutritionally balanced and tasted delicious. Lunch and evening meals are followed by a choice of dessert and cakes and biscuits are served with afternoon tea at 3pm. Virtually all residents spoken with were complimentary about the food provided at Mountside. Residents are able to choose where to take their meals, but for many this is seen as a social time. Tables in the dining room are arranged into small groups which provides an intimate and friendly environment to take meals. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 16 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from an open culture where they are able to express their views and feel valued and protected from harm. EVIDENCE: Mountside has a complaints policy which is accessible to both residents and visitors to the home. Neither the home nor the CSCI have received any formal complaints about the provision of service at Mountside in the last twelve months. The residents spoken with all confirmed that they knew how to complain and stated that if they had any concerns they would speak to the Manager. Similarly, the feedback from relatives and visitors was that they would be happy to discuss any issues with the Manager. The home also has a Residents’ Committee with a Chairperson who represents the views of the residents. The staff spoken with were knowledgeable about the vulnerability of residents and the systems in place to protect them. Staff have received training in the protection of vulnerable adults and prevention of abuse. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the clean, accessible and homely environment provided at Mountside, however the Registered Providers must ensure that there is a clear programme in place for managing maintenance and renewal. EVIDENCE: Mountside is an attractive detached property, which has been created by the joining of two large houses. The location of the home in a residential area on the outskirts of Hastings provides easy access to Hastings town centre and public transport links. Resident accommodation is provided on three floors, to which level access is provided by way of two passenger lifts, stair lifts and a series of ramps. Mountside is registered for thirty-three single bedrooms and five double rooms, Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 18 however all rooms are available as single occupancy only, unless a resident makes an express wish to share. Communal facilities include a range of pleasantly furnished lounges and a large dining room. The home also boasts extensive award winning gardens to the front and rear of the property. Parking is available at the front of the home. During the inspection, the Inspector undertook a partial tour of the home and found that all parts viewed were clean, hygienic and free from any offensive odour. Those bedrooms seen were all noted to be well equipped, clean, spacious and suited to the needs and wishes of the individual. Those residents spoken with confirmed that they liked their rooms. A number of areas requiring maintenance were however, identified during the inspection. The home is therefore required to produce a maintenance plan that evidences how the process of repair and renewal will be implemented to ensure Mountside is maintained as a safe and homely environment. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being supported by an experienced and committed team of staff and are protected by the robust recruitment systems in place. EVIDENCE: On the day of inspection, there were sufficient staff to support the needs of residents as detailed in the care plans. Rotas indicated that staffing levels provide four care staff and a Senior Carer in the morning and three care staff and a Senior Carer between 2pm and 8pm. At night, the home is staffed by three waking carers. In addition to care staff the home employs adequate numbers of cooking and domestic staff. The majority of feedback received indicated that staffing levels were sufficient, however it was commented by three relatives / visitors that staffing levels are not always adequate. Two residents also commented that “staff are always very busy” and “staff seem to be lacking a bit at the moment”. The Inspector spoke with the Registered Manager and staff who confirmed that they believed that staffing levels were adequate at this time. The Inspector did however comment that the way staff are deployed could be more effectively managed, for example the way medication is currently managed ties up the Senior Carer for long periods of time. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 20 All of the residents spoken with commented on how nice staff were. One resident expressed: “staff are very, very kind, no complaints” and another told the Inspector “staff are very nice, couldn’t be better”. Feedback from relatives and visitors was equally positive about staff “the entire staff have obviously been carefully selected for their kindness and competence” and “ staff are very caring to the residents”. The interaction between residents and staff was observed to be positive. Staff training is ongoing and the Manager reported that seven staff members have now completed National Vocational Qualifications (NVQ) to at least Level 2 and a further six staff are due to commence this training in January 2007. The home has a system for updating training in place and whilst not all staff were fully up to date with all courses at the time of the inspection, it was evident that staff have received a raft of training and there were updates already booked for mandatory training such as manual handling. The Registered Manager reported that all new staff complete an induction and that the new programme is in line with Skills for Care. The recruitment files for three new care staff were inspected and the required information was in place for each individual, including satisfactory checks with the Criminal Records Bureau, two written references, completed application form and full employment history. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 21 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, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the commitment of a skilled and experienced Manager who ensures that the home is well managed and run in the interests of the people who live there. Systems are in place to self-audit, but improvements can only be continued if there is additional management support. EVIDENCE: The Registered Manager at Mountside is a skilled and experienced practitioner who has worked in a senior management capacity for a number of years and possesses both Graduate and Professional Nursing qualifications, (SRN, B.Ed(Hons), RNT, Dip Nursing (Lond)), relevant to her position. She continues to undertake periodic training courses to update her knowledge and keep her nursing pin active. The Manager is dedicated to her position and works long Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 22 hours each day and assumes on-call responsibility every evening. The Manager’s commitment to her work is reflected in the positive feedback gathered during the inspection process. All residents spoken with were extremely complimentary about the Manager and comments included; “Matron is very good and you can always see her”. Throughout the inspection it was observed that the Manager had a good relationship with the residents and knew and understood each of their needs. Whilst the outcomes for people living at Mountside continue to be good, the Commission is concerned that the lack of additional management support is potentially risky. The home previously operated with two Deputy Managers, but in the period of the last twelve months both these individuals have left employment at Mountside. Due to the lack of success in recruiting to these positions, the structure of the home has now changed and the Manager is supported by three Senior Carers. Whilst these individuals are excellent carers, they do not have management experience to run the home in the Manager’s absence. It has long been identified through the inspection process that the Manager needs greater management assistance to assist the overall running of this size of home and the Registered Providers are requested to seriously review the management structure at the home. The home has a number of systems in place to audit and review the services provided. The home has a Residents’ Committee that meets twice yearly and minutes for the last meeting were viewed. The Inspector met with the Resident Chairperson who confirmed that the home was running well and that there “were no major issues at the moment”. The home also formally meets with relatives on a bi-annual basis too. Minutes from the last staff meeting were seen and it was evident that whilst meetings are not held more than twice each year, the meetings are professional and well structured. The Registered Providers undertake regular unannounced visits in accordance with Regulation 26. The records maintained on those few residents where the home manages their personal finances was found to be in order. All items purchased where found to be itemised with receipts in place. All monies coming were accounted for with an accurate up to date running total maintained. The home only handles money where there is no alternative. The Manager reported that she has introduced a system for the formal undertaking of supervision sessions. Again, this was not entirely up to date, but it was evident that a system is in place and the Manager is clear what the expectations are. The information submitted to the Commission prior to the inspection indicates that the home has a number of systems in place to ensure the health and safety of the home is monitored and maintained. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 23 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 X 3 X 3 3 X 3 Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 24 YES 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 OP7 Regulation 15(1) Requirement The Registered Person must ensure that the needs of all necessary Service Users [Residents] are reassessed. From the assessments, detailed advice should be included on the level of care to be provided to each service user. Progress with the plans should be monitored and reviewed in line with National Minimum Standards. That the new Care plans are fully completed and include information on service users interests, hobbies, and all other areas as listed in the plans [Previous timescales not met. Requirement first made in 2003]. 2. OP9 13(2) The Registered Person must 01/03/07 ensure that medication is dispensed, administered and recorded appropriately. This requirement particularly refers to the need to review the current system of one person dispensing all medication prior to DS0000064443.V304789.R01.S.doc Version 5.2 Page 25 Timescale for action 01/07/07 Mountside Residential Home 3. OP19 23(2)(b) 4. OP27 18(1) administration. The Registered Person must produce a maintenance plan to evidence how the home is to be maintained in a good state of repair. The Registered Person must ensure that an additional suitably qualified person must be appointed to assist the manager in addressing the work required to improve the care plans and risk assessments. [Previous timescales not met. Requirement first made in 2004]. 01/04/07 01/05/07 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. Refer to Standard OP12 OP31 Good Practice Recommendations That the home consults with the service users (residents) about the changes to activities in the home. That the home recruits or puts someone forward to complete the National Vocational Qualification level 4 in Management and Care. Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Mountside Residential Home DS0000064443.V304789.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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