Inspection on 27/04/05 for The Mellowes

This inspection was carried out on 27th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Mellowes 16/05/06

The Mellowes 04/10/05

The Mellowes 03/11/04

The Mellowes 15/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Mellowes Common Mead Lane Gillingham Dorset SP8 4RE Lead Inspector Chris Gould Unannounced 27 April 2005 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 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. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Mellowes Address Common Mead Lane Gillingham Dorset SP8 4RE 01747 824400 01747 826699 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes (CFC Homes) Limited Mrs Jane Jones Care Home with nursing CRH (N) 48 Category(ies) of OP - Old age, not falling within any other registration, with number category (48) of places The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a maximum of 39 service users who require nursing care. 2. Maximum of 3 double bedrooms in use at any time, nos 2, 25, 26, 36, 44 & 45 (referred to as guest suite). 3. The home may accommodate a maximum of 2 service users between the ages of 35yrs and 65yrs at any one time, not exceeding the registration number of 48. Date of last inspection 3rd November 2004 Brief Description of the Service: The Mellowes is a purpose built care home situated on the outskirts of Gillingham and was purchased by BUPA in June 2002. It is registered to accommodate forty-eight residents with a maximum of thirty nine requiring nursing care. The residents accommodation is spread over two floors with a passenger lift enabling easy access throughout the home. There are 45 bedrooms, all with en-suite facilities, three communal lounges and a large dining area. The home has five assisted bathrooms and an assisted shower available for use. The extensive grounds have lawns, seasonal flower borders, a sensory garden, an Italian style courtyard with water feature and a gravelled driveway with a car parking area. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over seven hours on one day in April 2005. This inspection assessed 20 standards and the outstanding requirements from the previous inspection. A tour of the premises took place and four staff files and four residents care records were inspected. Fourteen residents, five visitors to the home and the staff on duty were spoken with during the inspection. Jane Jones the registered manager was unavailable so Moira Hill the deputy manager ably assisted in the inspection process. What the service does well: What has improved since the last inspection? Staff have now received training on the procedures for protecting adults from abuse. A device has been fitted to allow the door of the quiet lounge to be held open. The Commission for Social Care has registered Jane Jones as the manager and the home’s statement of purpose has been updated to reflect the change in management. Additional storage space has been found for aids and equipment that were previously stored in corridors and bathrooms. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 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 Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 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 standard(s) 1, 3, The home does not provide intermediate care therefore standard 6 is not applicable. The homes Statement of Purpose and Service User Guide ensure residents have the information they require before moving into the home. The systems in place ensures that the resident knows that the home they are moving into provides suitable facilities and that their care needs will be met. EVIDENCE: BUPA has produced a corporate brochure with inserts containing additional detailed information relevant to The Mellowes. The information is given to all prospective service users providing a detailed service users guide. This was confirmed by the residents and relatives spoken with who agreed that the information provided a clear picture of the services and facilities available. Since the last inspection the Commission for Social Care has registered Jane Jones as the manager and the information has been updated to reflect the change in manager. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 9 Individual records are maintained for each of the residents. Inspection of the records for the two most recent admissions contained a detailed pre admission assessment of care needs including information from professionals previously involved in providing their care. Discussion with staff confirmed that they were aware of the resident’s needs at the time of their admission. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 10 All residents have individual care plans to meet their health, personal and social needs. Residents’ health care needs are fully met and they are treated with respect and their right to privacy is upheld. EVIDENCE: All residents have individual plans of care based on a pre-admission assessment of need. The four residents care records inspected had been reviewed at least monthly. The care plan provided a clear record of the resident’s needs, the expected outcome and the action plan to meet the assessed needs. The records included input from health care services including General Practitioners, community nurses, the tissue viability nurse and the palliative care nurse. Two residents spoken with had recently been provided with pressure relieving mattresses to meet their changing needs, this was reflected in their care plan. The residents spoken with were all in agreement that staff were aware of their needs and the help they required. One resident commented ‘they do everything possible sometimes the impossible. They do everything in their power to help’. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 11 Staff induction includes respecting residents privacy and dignity. This was confirmed when speaking with staff. Staff were seen knocking on doors and waiting for an answer before entering residents rooms. Residents spoken with said that they were always addressed in the way they had requested. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 A flexible approach is taken in the running of the home and residents are helped to have a choice over their lives. Social activities provide variation and interest for the residents living in the home. Residents are able to maintain contact with their family and friends and to go out into the community if they wish and are able. EVIDENCE: An activities organiser works twenty five hours a week and outside entertainers provide a varied recreational programme. A copy of the activities programme for the month is provided for all residents and the activities for the day are written in large print on a flip chart at the entrance to the dining room. Suggestions for future activities are included on the agenda for the residents meeting. The activities organiser visits residents individually as well as providing group activities. On the morning of the inspection an activity took place with a small group and in the afternoon a quiz with a larger group of residents. Residents spoken with agreed that the programme provided something for everyone. One resident commented ‘the nice thing is I can join in if I want to depending on how I feel on the day’. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 13 Residents spoken with all said that they choose the time they get up and go to bed. One resident commented ‘if I want to stay in bed a bit later than usual that’s no problem’. Menus are provided at coffee time for residents to choose their breakfast, lunch and supper for the following day. A book in the reception area shows that the residents receive a large number of visitors at various times. Residents have a telephone in their room and a number of residents spoken with said that although their relatives and friends were not able to visit as often as they would kike to they kept in touch by telephone. Outings are arranged for those who wish to go out. In April The Mellowes hosted a visit from the residents of one of the BUPA sister homes. This was reciprocated when the residents of The Mellowes visited the other home later in the month. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 The systems in place provide residents with the confidence that their complaints will be taken seriously and acted upon and that a safe environment is provided to protect them from abuse. Residents’ legal rights are protected. EVIDENCE: The home has a detailed complaints procedure that is included in the service user guide. Residents’ spoken with said that they were aware of the procedure and what to do if they had a complaint. One resident said that when they had complained ‘it had all been dealt with very well and quickly and I was even asked if I was happy with the result.’ Since the last inspection staff have received training in adult protection. This was confirmed in discussion with staff and inspecting training records. Inspecting residents care records and speaking with residents confirmed that they have representatives, including family and solicitors, to manage their affairs and act as their advocate. Postal votes are available for all residents who wish to vote in the forthcoming general election. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 22, 24, 26 The standard of the environment is good providing the residents with a clean, comfortable and well maintained place to live. Residents are able to personalise their own rooms. Fire safety recommendations need to be fully implemented to ensure residents live in a safe environment. EVIDENCE: A full time maintenance worker is employed and a documented programme of routine maintenance, redecoration and refurbishment is maintained. Since the last inspection an electro-magnetic hold open device has been fitted to the door of the quiet lounge. The recommendations by the Fire safety Officer have been met with the exception of fitting smoke detectors to under stair cupboards but this is being addressed. Additional cupboard space has been provided for the storage of equipment. Recommendations provided following the assessment by a qualified Occupational therapist have still to be addressed. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 16 Visiting residents in their rooms demonstrated that they had been personalised with their own small personal effects including photographs, pictures, ornaments and small pieces of furniture. Two service users spoken with had recently had their rooms decorated in a colour they had chosen. A duvet cover in their chosen colour had been provided for one resident. A call system is fitted in all areas used by residents and records are kept of the time taken by staff to respond to calls. Residents spoken with said that if they use their call bell someone arrives fairly quickly. On the day of inspection the home was clean and no malodours were noted. An infection control procedure is in place and all staff have received training. This was confirmed in discussion with staff. All residents and visitors spoken with commented positively about the laundry service and the cleanliness of the home. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The levels of staffing and the staff training provided meet the needs of the residents and appropriate checks are being undertaken prior to the member of staff commencing employment to ensure residents are supported and protected. EVIDENCE: The duty rota demonstrated that there are a sufficient number of registered nurses, health care assistants and ancillary staff on duty to meet the staffing notice issued by the previous regulator, the Dorset Health Authority. Residents spoken with all commented that there was always someone there when you needed them and that they were always very caring. One resident said ‘I know they must be very busy but I never feel that I have to hurry’. Another resident commented ‘I get help when I need it’. Four staff files were inspected and they all contained the relevant documentation and checks required including a satisfactory enhanced Criminal Records Bureau or POVA first check prior to the member of staff commencing employment. Of the 35 health care assistants employed 16 have achieved an NVQ in care at level 2 or above and 3 more are at present undertaking the training. Training records demonstrated that all new staff undertake an induction programme. Ongoing training is provided to cover mandatory subjects and to meet the special needs of residents including those associated with specific diseases. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 18 This was confirmed by the staff spoken with that all felt that they were well trained to do their job. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 38 The management of the home enables residents to live in an atmosphere that is caring and supportive. Systems are in place to ensure that the welfare of residents is promoted and protected. EVIDENCE: Minutes are available of regular meetings arranged for all staff according to the department in which they are employed to work in the home. Bi monthly residents meetings take place and this was confirmed by residents. Staff spoken to said that they felt able to put forward ideas or suggestions they may have and that they would be listened to. Residents commented that it was a ‘happy’ and ‘well run home’ and that they ‘were well cared for’. Servicing records evidenced that regular tests and safety checks are undertaken including fire alarms and equipment for the prevention and detection of fire. Residents commented on the recent fire drill that involved The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 20 the partial evacuation of residents. The drill was fully recorded and action has been taken to ensure that sufficient wheelchairs are now available. Training records and staff confirmed that training has been provided in manual handling, food hygiene, health and safety, infection control, first aid and emergency procedures. The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x x 2 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x 3 x x x x x 3 The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 22 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 19 Regulation 13(4) 23(4) Requirement The matters in the Fire Safety Officers report dated October 2004 must be addressed. Timescale of 31 January 2005 not met The recommendations relating to the facilities and premises, set out in the homes recent assessment undertaken by a qualified occupational therapist, must be addressed. Timescale of 31 March 2005 not met. Timescale for action 31 July 2005 2. 22 13(4) 23(1)(a) 31 July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole Dorset BH17 0NF 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 The Mellowes D55 S28980 The Mellowes V220443 270405 Stage 4.doc Version 1.30 Page 24 - 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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