Inspection on 20/12/05 for Mountwood Care Home

This inspection was carried out on 20th December 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

Mountwood Care Home 08/11/07

Mountwood Care Home 24/07/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Mountwood Care Home 11 Millway Road Andover Hampshire SP10 3EU Lead Inspector Sue Maynard Unannounced Inspection 20th December 2005 09:00 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 Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mountwood Care Home Address 11 Millway Road Andover Hampshire SP10 3EU 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) 020 7929 3444 01264 363081 mountwood@ashbourne.co.uk Ashbourne (Eton) Limited Mrs Sharon Tucker Care Home 49 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (49), of places Physical disability (1), Physical disability over 65 years of age (49) Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd July 2005 Brief Description of the Service: Mountwood Care Home provides accommodation for 49 service users in the categories old age and dementia, requiring nursing care. The home includes an EMI unit with 11 bedrooms, a dining room and sitting room. The home has recently undergone a further change of ownwership from Ashbourne Healthcare to the Southern Cross group of homes. The management structure within the home is unchanged, with Mrs Sharon Tucker as the Senior Manager. Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second statutory unannounced inspection for 2005/2006. The inspection was conducted by one inspector and lasted four and half hours. The manager was present throughout the inspection. A tour of the building was made and records were examined. The inspector spoke to six residents and four members of staff. Feedback from residents and staff was very positive. Staff and residents stated that communication between the manager and her deputy is very good. The residents spoken to confirmed that always felt comfortable in discussing any concerns they had with both the manager or any other member of staff. Members of staff confirmed that the training they receive and support from the manager and her deputy enables them to maintain a high standard of care in the home. What the service does well: What has improved since the last inspection? Since the last inspection a programme of formal supervision has been introduced for all trained staff members. All members of the staff has a personal development file which contains records of training, supervision and appraisal. The deputy manager has recently undertaken a training course for the Awareness of Abuse in the Elderly and will be providing training for all staff in the home. This training will provide backup for the guidance provided in the Hampshire Protection of Vulnerable Adults procedure. This will ensure that all Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 6 staff are aware of the procedure to be followed when reporting an incident of abuse. Fire safety records now demonstrate that all staff signatures are obtained when they attend fire safety training. 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. Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 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 Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 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 Arrangements for assessments are in place, prior to admission, which ensure that the needs of the resident can be met. Standard 6 is not applicable to this service. EVIDENCE: Prior to admission to the home the registered manager or her deputy undertakes a comprehensive assessment of the prospective resident. This assessment is carried out either in the person’s home, the hospital or previous residential placement. All the physical and psychological needs of the resident are addressed during this assessment. The inspector saw copies of these assessments in the three residents’ files and evidence was seen that information had been obtained from other health professionals and members of the resident’s family. This assessment identifies the health care needs of the resident and forms the basis for care plans that are written to address all the care needs of the resident. One resident recently admitted to the home stated that she was very happy and that the staff had made her feel very welcome and that “the atmosphere Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 9 in the home was lovely”, and that she was very pleased that she had made the decision to move into the home Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 10 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 and 8 The care planning and communication systems in the home ensure that the health and care needs of the residents are met in a way that respects their privacy and dignity. Standards 9 and 10 were assessed during the inspection undertaken in July 2005. EVIDENCE: The inspector examined records for three service users. All the records examined contained a very comprehensive pre-admission assessment. On admission to the home a further assessment is undertaken to provide further information allowing the staff to identify the individual care needs of each resident. Personal details documented, included the contact details for the service user’s next of kin, date of birth, the date that they were admitted to the home, and the doctor with whom the service user was registered. Care plans had been drawn up to address all the care needs of the resident. The care plans identified the problem and clearly demonstrated the action plan Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 11 and the outcome that was to be achieved, ensuring that the health care needs of the resident is met. All documentation used in the home is undergoing review. The preferred format of documents for Southern Cross is will be introduced for all new residents. Residents are able to access dental and optical care as required. Podiatry care is provided every six weeks for the residents and they are able to choose whether they receive the service from a male or female podiatrist. The manager undertakes a monthly audit of all residents who have pressure sores. Currently four residents have pressure sores. Three of the residents acquired the lesions whilst receiving treatment in hospital. Regular risk assessments are undertaken for tissue viability. Residents that are identified as being at even low risk are provided with a pressure relieving mattress. Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 12 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): These standards were assessed during the inspection undertaken in July 2005 EVIDENCE: Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 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 The complaints procedure for the home will ensure that any complaints received by the home will be handled objectively. EVIDENCE: The home has a detailed complaints procedure that is available in the home’s Statement of Purpose. No complaints against the home have been received by CSCI since the last inspection. Residents spoken to confirmed that their concerns are always taken seriously and acted upon. The manager reported that daily communication with the staff and residents enables her to address any problems that arise, immediately. Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 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): These standards were assessed during the inspection undertaken in July 2005. EVIDENCE: Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30 Comprehensive training undertaken by the staff enables them to be competent to do their jobs. The recruitment procedure for the home ensures the vulnerable people living in the home are protected. EVIDENCE: The home has a very comprehensive training programme. Staff are supported to undertake relevant training that provides them with additional knowledge to maintain the continuing high standard of care in the home. All new staff employed by the home undertakes a period of induction training during which time they work supervised by a senior member of the care staff. The deputy manager is responsible for the training programme in the home. A training record for each staff member is maintained and is audited each month. The audit enables the deputy manager to identify the learning needs of individual staff members. 43 of the care staff in the home has achieved NVQ training at level 2 and 3. The manager reported that four staff members will be commencing NVQ level 2 in the New Year. The inspector examined samples of staff recruitment files for four members of staff. For each staff member the records demonstrated that written references and proof of identity had been obtained. An application form had been Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 16 completed, and appropriate checks have been undertaken with the Criminal Records Bureau and the Protection of Vulnerable Adults register. All prospective new staff members are interviewed before an offer of employment is made. A record of this interview is documented. Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 17 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 manager of the home is able to demonstrate that she is suitably qualified to ensure that the home is well run and that the needs of the residents are met. The manager provides strong leadership in the home providing guidance and direction to ensure that standards within the home are maintained at all times. Close monitoring of practices within the home safeguard the health, safety and welfare of residents, staff and visitors to the home. EVIDENCE: Mrs Sharon Tucker is the manager for the home and has been in post since 2001. She is Registered General Nurse, Level 1. Her post registration Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 18 qualification includes a Foundation degree in Care Home Management, ENB 941- Care of the Elderly. Mrs Tucker has also undertaken training in Mentorship and Assessment. Staff and residents were very positive about the way the home is run. The manager has an “open door” policy that enables staff and the residents and their families to discuss issues as they arise. Regular meetings are held for both staff and the residents and their families. The manager audits all services in the home each month. A quality assurance system is in place. Questionnaires have been sent out to residents and their families. From the responses received the manager is able monitor the level of satisfaction about the care and services provided in the home. The home does not look after resident’s money at this time. On the day of the inspection a new central heating boiler was being installed following the breakdown of the existing system. Inspection of records indicated that regular tests are undertaken of all equipment and systems used in the home, including fire safety equipment, emergency lighting and extinguishers. The records also demonstrated that fire drills and instructions take place regularly. Staff members spoken to confirmed this. Staff undertake regular training for: Fire safety Safe moving and handling Infection control First aid Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 19 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 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 20 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. Refer to Standard Good Practice Recommendations Mountwood Care Home DS0000065933.V270202.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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