Inspection on 08/11/07 for Mountwood Care Home

This inspection was carried out on 8th November 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 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 24/07/06

Mountwood Care Home 20/12/05

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 Peter J McNeillie Key Unannounced Inspection 8th November 2007 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.V349824.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. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 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) 01265 333800 01264 363081 mountwood@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Neil Young Care Home 49 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0), of places Physical disability (0), Physical disability over 65 years of age (0) Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The registered person may provide the following categories of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) Physical disability over 6 (PD (E)) Physical disability (PD) Dementia - (DE (E)) maximum number of places 11 2. The maximum number of service users to be accommodated is 49. Date of last inspection 24th July 2006 Brief Description of the Service: Mountwood is a registered care home offering nursing care and personal support for up to 49 Residents in the categories old age and dementia. Within the home there is a separate dementia Care Unit with 11 bedrooms, a dining room and sitting room. The home, which is owned and managed by The Southern Cross Group of homes a national provider of similar services, is situated within a mile of the centre of the North Hampshire town of Andover and close to local amenities. Since the last inspection the manager has been registered and a new deputy manager appointed. At the time of the fieldwork visit to the home on 8th November 2007 the home’s fees ranged from £442 to £839 per week. This did not include the cost of hairdressing; newspapers; chiropody and dry cleaning. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced visit was the first inspection for the years 2007/08 and took place on 08/11/07 between the hours of 09.00 am and 2.00 pm during which all of the key standards for care homes for older people were assessed. A number of sources of information and evidence were considered in producing this report including observations made during a visit to the home, notifications to the Commission for Social Care Inspection (CSCI) under regulation 37, examining residents assessments, care plans, staff training and recruitment records, policies and procedures, comments by management, staff, residents, visiting residents relatives, the results of an in house residents satisfaction survey results from a CSCI satisfaction survey and information provided by the manager in a statutory Annual Quality Assurance Assessment (AQAA) . During this visit at which we were assisted by the registered manager a number of residents and staff were spoken with individually and in groups. The results and findings contained in this report will determine the frequency and type of future inspections. What the service does well: What has improved since the last inspection? 1) Two corridors have been re carpeted, a bathroom refurbished and the dementia wing repainted. 2) Staff training in the needs of persons with dementia. 3) Improved communication with more regular staff and management meetings and staff supervision. Mountwood Care Home DS0000065933.V349824.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. Mountwood Care Home DS0000065933.V349824.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 Mountwood Care Home DS0000065933.V349824.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of assessing and identifying residents needs which ensures their safety and that there assessed needs can be met. Intermediate care is not available. EVIDENCE: The home had written policies and procedures concerned with the admission of new residents to the home and these referred to the importance of ascertaining the help required by potential residents before they moved into the home. The home’s Service Users Guide stated the following: “Prior to admission the Home carries out a detailed assessment often in conjunction with other health and/or care professionals, to ensure that the Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 9 staff are able to meet your care needs and that any appropriate equipment is in place…………….We avoid unplanned admissions where possible”. A sample of three residents records and pre admission assessments of need and risk were viewed. All of the records viewed confirmed that potential residents are only admitted following a full assessment of their care and nutritional needs and risks by the manager or another member of the homes management team. All potential residents and residents’ representatives are invited to visit the home for a meal or an overnight stay prior to an admission being agreed. As part of the admission process management also liaise with external health care professionals regarding any care needs, risks, equipment and aids that need to be taken into consideration when developing a plan of care. All residents’ assessments and care plans are kept in resident’s own rooms. Residents spoken with confirmed that they were consulted and contributed to the assessment process but there was no written confirmation of this in the records viewed. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The arrangements for planning care are clear ensuring that the health, personal care and medication needs of residents are met and their privacy and rights respected. EVIDENCE: A sample of three residents care plans which are kept in residents own rooms were viewed and a number of residents spoken to individually or in groups. All of the detailed care plans which were reviewed at least monthly were based on pre admission assessments the home had carried out in order to identify what help individuals needed (The previous section, choice of home standards 1-6 of this report refers). Whilst some residents verbally confirmed they were consulted about and participated in the production of the plan, others could not remember and in Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 11 some instances were probably not able to participate in a constructive and meaningful manner due to their dementia. There was no written confirmation by residents or their representatives to confirm their participation. All of the residents spoken with confirmed they were very satisfied with the care and support they received, contented, liked the staff and management, were treated with respect felt wanted and would recommend the home to anyone”. Residents responses to our questions relating to how they were cared for and liked living in the home were all very positive and included comments such as “ Hotel service”” I am more than happy”,” Well satisfied”,” Care is very good” “The staff are great”.” You wont find anything wrong here”, ”The best”. Residents confirmed that staff always knocks on their bedroom door and wait before entering, a practice we observed during this visit. Residents spoken with confirmed they were able to see the doctor of their choice or any other health and social care professional when they needed to. The records viewed indicated that apart from doctors, district nurses, physiotherapists, occupational therapists, other specialists had been consulted when required. Records were kept of appointments with GPs, dentist, optician, chiropodist and any other external health and social care professional and included details of any advice and treatment given. Medication records confirmed that all prescribed drugs and medicines, which are securely stored, are dispensed by a pharmacist into a blister pack system and administered by a trained nurse. The record of drugs and medicines administered to residents and unwanted drugs disposed of were complete and accurate. A procedure that ensures residents who wish may assume responsibility for their own medication was in place. Records indicated following a risk assessment no residents were responsible for there own medication. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social activities, family contacts and the provision of varied and nutritious meals were well managed and reflected service users interests and choices. EVIDENCE: The home employed an activities organiser and there was a publicised programme of regular events and entertainments in which residents could participate was displayed in the entrance hall of the home. Activities on offer included, bingo, lunch club, sing songs, keep fit, dancing, games as well as visiting entertainers and occasional trips out to the local shops, town, pubs, restaurants and theatres. Residents confirmed there was plenty to do and that participation was up to the individual, no one was forced to join in. The home has regular visits from local Church of England clergy who conduct services and communion in the home. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 13 The needs of members from any other Christian denominations or other faiths can be catered for but at the time of this visit no members from other faiths were residing in the home. Residents confirmed they were fully consulted and were able to exercise choice in all aspects of their lives for example; when to get up and go to bed, mealtimes and where meals are taken, visiting times, the right to receive and converse with visitors and to make and receive telephone calls in private. The quality, quantity, presentation and choice of food served came in for particular praise from the residents who we joined for their mid day meal and are able to confirm their comments. A new recently agreed written daily menu based on resident’s likes and dislikes was displayed. The manager informed us that he was aware that the menu was displayed in a format that all residents may not fully understand and was in the process of converting the written text into a pictorial format. The homes staff and management recognised that alternatives to a written menu is of importance for persons with dementia who may find the addition of pictures would be beneficial to their understanding and assist in them making meaningful choices. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 14 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. The home has clear policies and procedures in place which ensures residents are protected from abuse. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon. EVIDENCE: An in house Adult Protection policy and procedure that operates in tandem with the policy and procedure produced by Hampshire County Council designed to safeguard residents from abuse was available. Records viewed and staff spoken with confirmed they had received training in recognising various types of abuse. All were able to demonstrate they knew the procedure to follow should they witness or suspect the abuse of any resident. The homes complaints procedure, which included information on how to contact The Commission for Social Care Inspection (CSCI), was seen, as was a record of complaints. The procedure, which was included in the service users guide was also displayed within the home. No complaints had been received by CSCI since the last inspection. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 15 Residents spoken with said felt comfortable in raising any concerns they had with the homes management or any member of staff and confident any matters raised would be dealt with fairly and promptly. Staff also confirmed they felt confident in raising any matter or complaint with the homes management on behalf of a resident. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 16 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): 19,24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home is provided for residents which meet their needs but locks have not been fitted to all residents bedroom doors. EVIDENCE: All areas of the home were clean and free from unpleasant odours and obvious hazards. Furniture was comfortable, homely and met residents needs. Residents spoken with confirmed the home is always clean, smells fresh. Since the last inspection as part of the routine maintenance programme, carpets on the ground floor and first floor corridors has been replaced, shortly Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 17 to be followed by the stairs, (New carpet on site awaiting carpet layers), one of the bathrooms has been refurbished including the fitting of a shower suitable for persons with severe mobility problems, four bedrooms have been refurbished and the section of the home where persons with dementia are being accommodated completely redecorated. The homes management recognise the special environmental needs for persons with dementia regarding colours, textures and patterns. Further plans are in hand that will involve changes to the present décor to take these special needs into consideration. Immediate plans include an extension to the kitchen and main and dining area utilising space in the centre of the building. We were informed these improvements should be completed by Christmas 2007. Currently only 12 out of 41 residents bedrooms have been fitted with a lock in accordance with the National Minimum Standards. No risk assessments to support the absence of locks were available. We highlighted with the manager that all bedroom doors should be fitted with a lock and the residents given a key if they choose to have one. The manager gave a verbal undertaking to carry out a risk assessment and discuss with residents who would like to have a lock fitted. Locks should then be fitted to all bedroom doors where residents request them immediately and on other doors when vacated by the current resident. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 18 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 excellent. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all residents. EVIDENCE: At the time of the inspection the ten care staff (including qualified nurses) on duty were supported by the registered manager, two cleaners, a laundry assistant, a handy man, a cook and a kitchen assistant two maintenance personnel and an activities coordinator. Residents who were full of praise for their carers confirmed the number of staff available ensured help was always prompt, efficient and carried in a pleasant and discreet manner. Care staff commented they had ample time to carry out their tasks. Five care were available at night. Staffing levels are frequently reviewed and adjusted to ensure the assessed needs of residents are met at all times. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 19 As part of their terms and conditions of employment, all staff agrees to undertake N.V.Q training courses which they undertake following an in house and Skills for care induction/foundation course. Comprehensive individual staff induction and training records that detailed dates when training was completed and when refresher courses on additional subjects such as the administration of medication, food hygiene, infection control moving/handling, fire safety (including evacuation), protecting persons from abuse and first aid were due . The home management also ensure that all staff are able to fully care for and understand the needs of persons with dementia by arranging in depth training of two eight hour sessions for every member of management and care staff including qualified nurses. At the time of the inspection 64 of staff had been trained to N.V.Q level 2 with a further 8.0 currently on a course. Well maintained, presented and user friendly personnel records viewed confirmed all staff are recruited in accordance with a corporate equal opportunities selection and recruitment procedure which includes the completion of an application form, an interview, signing a rehabilitation of offenders declaration and satisfactory Criminal Records Bureau (CRB), Protection of Vulnerable Adults (POVA), immigration, qualification and reference checks. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 20 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): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures the health, safety and welfare of residents and staff are promoted and the home is run in the best interests of the residents whose views about living in the home are formally sought. EVIDENCE: The experienced manager who has been registered since the last inspection is a qualified general nurse and on the day prior to this inspection had been informed he had been awarded his registered managers award N.V.Q. level four. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 21 In talking with staff, we confirmed, since coming into post that the manager has established a well-defined management structure including the appointment of a deputy, designed to maintain and improve the care practices and communication within the home. This is being achieved in part by implementing regular management and staff meetings, regular individual staff supervision and carrying out regular resident residents relatives and visiting health and social professionals satisfaction surveys the results of which were displayed in the entrance hall. These surveys, which are carried out every four months, involve at least 25 of residents and their relatives. The views of the residents, which are converted into an action plan, are seen as key in highlighting areas that may require improvement or attention and the development of this service. Management both in house and external were described by staff as being available approachable and supportive. A representative of the organisation in accordance with regulation 26 undertakes monthly visits. Reports following these visits also assist in adding information to the action planning process. We were informed no resident’s cash was being held by the manager for safekeeping. A corporate health and safety policy was in place to ensure the day-to-day safety of staff and residents. Procedures include, weekly health and safety checks, the regular servicing of equipment, staff training in the techniques of moving and handling infection control, control of substances hazardous to health (C.O.S.H.H.) first aid, health and safety, reporting accidents and procedures to follow in the event of fire (including evacuation). All of the hot water supplies to baths were fitted with thermostatic controls are set at 43 degrees centigrade and all radiators and hot pipes covered. Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 22 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 3 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 3 X X X X 2 X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 23 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 OP24 Regulation 23(2) e. f Requirement To ensure residents privacy and dignity, risk assessments must be carried out and locks fitted to all residents bedroom doors where residents request them immediately, and on other doors when vacated by the current resident. Timescale for action 01/03/08 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.V349824.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Mountwood Care Home DS0000065933.V349824.R01.S.doc Version 5.2 Page 25 - 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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