Inspection on 19/06/08 for The Mellows

This inspection was carried out on 19th June 2008.

CSCI found this care home to be providing an Good service.

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

The Mellows 19/06/07

The Mellows 30/05/06

The Mellows 21/10/05

The Mellows 05/05/05

The Mellows 19/11/04

The Mellows 15/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Mellows 38 Station Road Loughton Essex IG10 4NX Lead Inspector Diana Green Unannounced Inspection 19th June 2008 09:30 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 The Mellows DS0000059391.V367082.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. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mellows Address 38 Station Road Loughton Essex IG10 4NX 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) 0208 508 6017 0208 508 4649 The Mellows Limited Mrs Bhavi Patel Care Home 23 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (23) of places The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 23 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 15 persons) The total number of service users accommodated in the home must not exceed 23 persons 19th June 2007 Date of last inspection Brief Description of the Service: The Mellows Care Home provides residential care for up to 23 older people (over 65 years), in twenty-one single and one shared room. The home is situated in the centre of Loughton within easy walking distance of local shops and amenities. Accommodation is provided on two floors, with three levels overall. Access to all levels is provided by a passenger shaft lift. There is a good-sized garden to the rear of the property, with a patio area accessed directly from the lounge/dining room. The home is accessible by road, bus and underground, with the nearest station and bus stops a short walk away. Parking is available for several cars in the private car park at the front of the building. The fees charged for care and accommodation at The Mellows ranged from £454.00 to £612.00 per week excluding personal items such as toiletries, chiropody services and hairdressing. The registered provider gave this information to CSCI on 19th June 2008. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key unannounced inspection that was undertaken on the 19/06/08. The inspection process included: discussions with the registered provider, the registered manager, care staff, the cook, a volunteer, the laundry assistant, four residents, two visitors, and feedback from relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Evidence was also taken from completed surveys and the Annual Quality Assurance Assessment (AQAA) completed by the management of the home and submitted to the CSCI. Twenty-seven standards were inspected and four requirements and four recommendations made. The registered manager and staff were welcoming and helpful throughout the inspection. What the service does well: The Mellows provides a clean, homely and friendly environment for residents and maintenance issues are in the main responded to without delay. The registered provide has purchased an adjacent property that is being converted to provide a care home. A relative told us that the recent building works had not been a problem and there had been ‘no disruption to premises –kept to a minimum’. The standard of personal care and healthcare are good with evidence of good monitoring of health care needs and appropriate action taken as needed. A relative told us ‘Our xxx has always been looked after extremely well’. The meals are homely type food and meals are seen as a social event. Nutritional needs are assessed and intake monitored. One relative when asked what the home did well told us ’‘keeps a clean home and feeds them well’. There is good retention of staff who are skilled and experienced. Staff are well trained and well supervised.’ Care staff are professional but friendly in their approach with residents. A relative told us ‘the whole staff are caring and considerate-every need is met’. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 6 The complaint procedure is promoted with residents and their representatives. All issues of concern are documented and used to improve practice. There is good consultation with residents with monthly meetings held where their views are listed to and acted on. There is good communication with residents’ families. One told us there is ’very good communication with resident’s family’ and another said ‘the care home has always been very helpful and we feel very welcome’. What has improved since the last inspection? What they could do better: The statement of purpose does not provide a full description of the service provided at the home (for example dementia care). The environment has some damaged paintwork that is in need of refreshing. There are a number of damaged headboards that need to be replaced. Locks were not provided on doors to residents’ rooms and no lockable facilities were provided. There were no outings provided for residents and not much entertainment provided. Some health and safety risks were found during the site visit (Chlorhexidine hand wash left out and an unlocked hot water storage cupboard). Hand washing facilities (liquid soap & paper towels etc.) for staff were not provided in all areas where personal care is provided. A malodorous smell was noted in a resident’s room. Some photographs of residents were not available and others were unclear. There was no temperature monitoring of medication storage. MAR sheets did not exactly correspond with that on the medication labels of prescribed medicines. There was no Controlled Drug (CD) storage or register, which is now a requirement for all care homes, including residential homes. The Mellows DS0000059391.V367082.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. The summary of this inspection report can be made available in other formats on request. The Mellows DS0000059391.V367082.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 The Mellows DS0000059391.V367082.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 1, 3 & 6. People planning to move to the Mellows can expect to be informed and to have their needs assessed prior to moving in to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose that had been kept under review, a copy of which was provided at the site visit. This included the facilities and services provided for residents together with management and staffing information required under the regulations. However the document was fairly brief and did not provide clear detail on how the home intended to meet the aims and objectives set out in the home’s policy, nor did it provide comprehensive information on the care of people with dementia, both of which would be very informative for residents and /or their representatives when looking for a care home. The home had a service user guide that was available for prospective residents and their representatives to enable them to make a The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 10 decision. The AQAA stated that relatives and the prospective residents and their relatives are encouraged to visit the home to help them make an informed choice. A relative spoken with confirmed they been invited to view the home and had seen the statement of purpose. The AQAA stated that a new initial assessment form had been developed and introduced since the previous key inspection. This was confirmed with the manager when the arrangements for admission were discussed with her during the site visit. For residents funded through the local authority a community care assessment form was obtained and an initial assessment of care needs undertaken by the manager to determine if the care needs could be met at the home. The manager stated that she attended the resident’s own home or hospital to undertake the assessment where possible and ensured full involvement of their relative or representative where possible. A full assessment was then undertaken within 48hours of admission. Four care records were viewed and all included a pre-admission assessment and a full assessment of care needs. Copies of care management assessments were seen held on file. This home does not provide intermediate care. The Mellows DS0000059391.V367082.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 7, 8, 9 and 10. The health and personal care needs of residents are appropriately met through care planning that is regularly reviewed and monitored. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were reviewed during the site visit. All included an assessment of needs and dependency assessment with a range of care plans for individual needs (for example personal care, oral care, foot care, sight and hearing, diet etc.) as indicated in this standard and included good detail of the residents needs. Risk assessments were undertaken and recorded for falls, nutrition, and moving and handling and skin integrity and risk assessment for history of pressure sores. All care plans had been reviewed monthly. Daily records were detailed and showed good monitoring of needs and appropriate action taken as relevant. When asked do you receive the care and support you need, nine residents who responded told us: ‘always’. Positive comments were also received from two The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 12 residents: ’all staff are good and I am very happy with the service provided; ’I chose the right home, I am happy here’. The records detailed visits by GPs, district nurses, chiropodists, opticians and attendance at outpatients as needed. Care staff spoken with were able to demonstrate that prompt action was taken to meet residents’ changing health needs, for example referring promptly to GPs to obtain treatment for residents who developed infections. However the manager said that some problems had been experienced by the home when requesting GPs to undertake a review of residents’ needs. From the positive comments received from relatives it was evident that residents’ care needs were monitored and they were kept informed: ‘Every need is met and catered for, the attention is wonderful and we couldn’t wish for more’; ‘very good communication with relatives’; and ‘I feel my xxx is looked after very well’. When asked ‘Do you receive the medical support you need? All nine residents who completed questionnaires responded ‘always’. The home had a policy and procedures for the safe ordering, administration recording and disposal of medication for staff guidance that had been kept under review. Medication was supplied in a monitored dosage system and in individual containers from the local supplying pharmacist. Senior care staff with appropriate training (confirmed from the records viewed) administered all medication. A list of those staff names and initials was available (confirmed as current by staff) but there was no staff signature recorded as recommended practice. Medication was stored in a locked cupboard situated in the small lounge on the ground floor and in a locked cupboard located on the first floor of the home. There was no evidence of room temperatures being monitored. The temperature taken at the site visit was 22.5°Centigrade and advice was given to ensure this was taken daily and recorded to ensure it did not exceed the recommended safe maximum temperatures of 25° Centigrade. There was no drug refrigerator and a domestic fridge was used to store medication (i.e. insulin, eye drops) that was required to be stored in a fridge and temperatures were monitored and recorded. There were no residents currently prescribed Controlled Drugs (CD) at the home. However the home had no CD drug cupboard or CD register. This is now a requirement for all care homes and advice was given following the site visit to obtain guidance from a pharmacist on the type of storage needed. The medication supplies and medicine administration records were viewed for four residents. Photographs of three residents were available but one was not clear and no photograph was available for the fourth resident. All medication was available as prescribed and records were well recorded. However medication administration records (MAR) sheets had been printed by the manager and did not mirror the instructions detailed on the medication labels. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 13 This was discussed with the manager during the site visit who agreed to ensure these detailed exactly the residents’ prescription. Residents spoken with said that staff respected their privacy and were respectful to them. However there were no locks on doors to residents’ rooms. This was discussed with the proprietor and manager who felt that locks would be inappropriate for the client group. Advice was given to ensure that this was detailed in the home’s policies, reflected in the statement of purpose and included in a risk assessment. There were no lockable facilities provided in residents’ rooms but the manager said that resident’s valuables could be held in the safe. The Mellows DS0000059391.V367082.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based upon sampled inspected standards 12, 13, 14 and 15. People living at The Mellows can expect to be supported to mantain contact with their family and friends, to have opportunities to engage in activities that satisfies their cultural expectations and a lifestyle that would be enhanced by more entertainment and outings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s AQAA stated that the home had a designated activities coordinator. A board displaying activities was seen to detail various activities. However there was not much going on during the site visit. Several residents were watching television and two residents were observed to be reading newspapers. Two residents were observed taking part in a snakes and ladders game with care staff and another in a game of darts. Two other residents were seen to spend time in the garden and one told us ‘ I like to go sit in the garden with my friend when the weather is nice’. ‘When asked ‘how do you think the care service could improve’ the following comments were received from relatives: ’more activities maybe in outside space. Encourage to help in the garden etc’; ‘more music for their own age’; ‘arrange some outings’; and one The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 15 commented that there used to be more entertainment provided. However plans for improvement for the next twelve months did not include entertainment or outings and were limited to taking ‘residents for walks in the garden and introduce armchair exercise. A training course has been booked for our activities coordinator’. The home’s statement of purpose included the policy on visiting and relatives spoken with at the site visit said they could visit at any time. Positive feedback was received in completed questionnaires from relatives: ’the communication is very good; they keep me well informed’. The home’s arrangements for meeting the spiritual needs of residents was included in the statement of purpose and the manager confirmed that representatives of different faiths visited the home as relevant. Residents were observed to have some choice about their daily life in the home, especially in regard to where they spent their day, ate their meals etc. One resident told us ’I like to go outside for a smoke with my friend xxx which is arranged by staff’ and another said ‘I like to stay in my room for my meals’. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them, subject to space. Information on advocacy services was included in the statement of purpose and available in the home. Discussions were held with the cook, menus viewed and a brief inspection of the facilities undertaken. The menus were provided over a four-week rotation with seasonal variations. The kitchen was small but clean and well organised. The proprietor explained that food supplies were purchased, as needed and large stocks were not held. Discussions were held with the cook who said that fresh fruit was provided that residents liked, for example grapes, bananas and melons. Mainly frozen vegetables were provided. Breakfast comprised cereals and toast. Residents were observed enjoying the lunchtime meal that comprised sausages with mashed potatoes and peas followed by desert. The manager said that residents had been consulted with and menus adapted but the outcome was that they preferred homely type food that they could manage to eat easily. Two residents spoken with during the site visit said the meal was ‘lovely’. Residents spoken with said their likes and dislikes were discussed with them and confirmed they could have an alternative. When asked ‘Do you like the meals at the home? Six residents responded ‘always and two residents responded ‘usually’. ‘The records viewed showed that residents’ nutritional intake was closely monitored and supplements provided as needed. The Mellows DS0000059391.V367082.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 16 & 18. People living at The Mellows can expect to have their complaints listened to and acted upon and to be protected from abuse by safeguarding policies, procedures, staff training and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that included the timescales within which complainants can expect a response and advised them of their right to refer to the placing authority. The procedure was attached to the statement of purpose and displayed in the entrance of the home. The home maintained a book to record any issues raised together with the action taken to address any concerns, that was viewed at the site visit and which is acknowledged to be good practice. All issues raised had been investigated in line with the home’s procedures. When asked ‘has the care service responded appropriately if you or the person using the service has raised concerns about their care? Three relatives who completed questionnaires when asked if the care service had responded appropriately if you or the person using the service have raised concerns about their care replied ’always’ and a fourth one said ‘usually’. Another relative said they had no concerns in eighteen months. All of the nine residents who completed surveys told us they knew how to make a complaint. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 17 The home had comprehensive policy and procedures for safeguarding vulnerable adults that were kept under review and local Essex procedures were available for staff guidance. However the recent updated multi-agency guidance published by Essex County Council was not available. The records confirmed that all staff had received relevant training. No referrals had been made since the previous key inspection. From discussion with the manager it was evident that she was clear on safeguarding adults and aware of the procedures to be followed in the event of any allegations being made. The training records seen confirmed that regular updated training had been provided for all staff. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate based upon sampled inspected standards 19, 22 and 26. People living at The Mellows can expect to live in a clean, homely and generally well-maintained environment but some standards of infection control place residents and staff at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made that included communal areas, bathrooms, a shower room, number of residents’ rooms, the kitchen and the laundry. The home was decorated and furnished to accordance with the client group and was observed to be generally well maintained (also confirmed from the records viewed). The AQAA stated that redecoration of ‘the lounge and communal areas’ had been undertaken and ‘new carpets, paint/wallpaper and curtains’ provided and ‘about fifty percent of furniture in the home has been replaced’. Some damage to paintwork from equipment was observed and radiators were The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 19 in need of paintwork being freshened up. The gardens were laid mainly to lawn with some shrubs and an arbour has been installed for residents to sit out in protected from the sun. A small patio lead from the rear exit of the lounge that was ramped to the garden. This had been partially screened from the wind and to obscure vision to the adjacent buiding works. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. A relative told us in a survey ’we feel we are very fortunate to have found a comfortable home for my xxx’. The home had a passenger lift to enable access throughout the premises. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home was accessible to wheelchairs. Call systems were provided throughout all individual and communal rooms. Pressure relief equipment was seen on beds and in chairs as assessed and provided by the district nursing service to meet the needs of residents. Hoist equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. All residents’ individual rooms were furnished to meet the National Minimum Standard. The AQAA stated that ‘all bedrooms have had the soft furnishings replaced’ and it was evident from observation that several residents’ rooms had been decorated and new carpeting provided. Some were nicely personalised showing that residents could bring their own personal items into the home (subject to space). However no locks were fitted and there were no risk assessments recorded (see standard 10). Several of the headboards fixed to resident’s beds of were damaged and required replacement. There were policies and procedures for infection control available for staff guidance. The standard of cleaning of the home was generally good. Hand washing facilities (liquid soap and paper towels) were provided in some bathrooms and shower rooms but not in all areas where personal care is provided (i.e. residents’ rooms/en-suites). Tablets of soap were in communal use that contravenes infection control guidance and there were no foot operated bins provided. There were no malodorous smells with exception of one room that was discussed with the manager during the site visit and it was evident that efforts were being made to meet the specific needs of the resident. The home had a designated laundry assistant who also assisted with some domestic tasks and who worked Monday to Friday. Care staff provided some laundry duties at weekends. The laundry room was located in the basement. The flooring had some damage meaning that it was no longer impervious in parts. However the Proprietor said that the laundry would be upgraded as part of the planned refurbishment. There were three washing machines (two in use) and one drier. Systems were in place to minimise the risk of infection via the use of disposable gloves and red bags for any laundry soiled by body fluids, placed directly in the washing machines. It was confirmed that washing The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 20 machines had the capacity to carry out sluice wash cycles. Feedback was received from a relative that sometimes the laundry was mixed up with others but the standard of laundry was otherwise good and their loved one was always dressed in clean clothes when they visited. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good based upon sampled standards 27, 28, 29 & 30. People living at The Mellows can expect to be cared for by skilled, experienced and caring staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were twenty-three residents at the home and staffing levels comprised three senior care assistants and one care staff. The registered manager, cook, laundry assistant, maintenance/gardener, one domestic staff were also on duty. There was evidence from the staff rota that staffing levels were well maintained and from observation these appeared to meet residents’ needs. Residents who completed surveys told us’ the staff are all very kind and helpful’; ’I am happy here, the staff are very kind’; the staff are always there for me’. Information received in the AQAA stated that the home had 9 care staff with NVQ level 2 qualifications or above out of a total of 14 staff which is above the 50 needed to meet the standard. A further 4 staff were working towards the qualification. The manager informed us that several staff were qualified nurses from overseas and she was seeking advice on whether this could be taken account in relation to an NVQ qualification. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 22 No new staff had been recruited since the previous key inspection. The manager informed us that new systems had been put in place to ensure references are verified for all staff including those recruited from overseas. Three staff files were checked and all three files included evidence that the required checks had been undertaken prior to appointment. All had correspondence from the home and agency to evidence that references were verified prior to appointment. The manager reported that Skills for Care Induction packs had been obtained and would be introduced for all new staff. A staff member spoken with said they had undertaken an update in first aid training and felt very supported by the manager. The training records were viewed for three staff and confirmed they had completed training on health and safety, fire safety, protection of vulnerable adults, moving and handling. The deputy manager had also undertaken medication training and to become a trainer in safeguarding adults. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good based upon sampled standards 31, 33, 34, 35 & 38. People living at The Mellows can expect to live in a home that is well managed and run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager had managed the home for several years. She holds a postgraduate management qualification, has experience in management systems and holds the RMA (Registered Manager’s Award). The manager was supported by a deputy manager who had worked at the home as a senior care assistant for some years. From discussion with the manager and an inspection of the records it was evident that both had undertaken recent updated training The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 24 relevant to a management of a care home for older people. A relative also told us’ the establishment is in my opinion very well run and maintained’. The home’s quality assurance system was discussed with the registered manager during the site visit. The manager said that she operated an open door policy and was available to relatives. A satisfaction survey had been distributed and a report produces with an action plan with timescales for service improvement. Comments were received from a relative ‘I usually see the deputy…and the staff are helpful and friendly’. Regular meetings were held with residents and staff and minutes of those were viewed. The manager explained that she planned to develop customer care with further consultation with relatives and strengthen communication with resident’s individual key workers. Neither the manager nor staff were appointee for any resident at the home. All residents had a representative/advocate to manage their finances on their behalf. All expenditure was invoiced directly. The home held a small amount of money in lockable facilities for some residents’ personal use. However whilst a record of transactions was maintained, no receipts were kept. From discussion it was evident that any resident who was subject to financial abuse would be referred under safeguarding procedures. The manager explained during the site visit that there was ongoing supervision of staff with formal documented supervision also in place. Supervision included staff practice, and staff training needs. This was also confirmed through discussion with staff and from the records inspected. A member of staff spoken with said they felt very supported by the manager’. Records held on behalf of residents were kept up to date and were stored safely in secure facilities. Records viewed at this inspection included: the statement of purpose, service user guide, assessments/care plans, medication records, complaints, staff meetings, staff recruitment and training records, maintenance records and fire safety records. The home had health and safety policies and procedures that were regularly reviewed. The records confirmed that staff had attended relevant health and safety training. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment fire alarms and emergency lighting etc.). The accident records were viewed and were well recorded with appropriate action taken. However two health and safety issues were evident during the site visit including an unlocked hot water cupboard and a chlorhexidine hand wash left within reach of residents. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP9 Regulation 13(2) Requirement Timescale for action 31/08/08 2. 3. OP24 OP26 13(4) 13(3) 4. OP38 13(4) To ensure the safe storage and administration of medicines: 1. Room storage temperatures must be monitored and recorded 2. A CD storage cupboard and CD register must be provided. To ensure the comfort and safety 30/09/08 of residents, damaged headboards must be replaced To ensure the risk of infection is 30/07/08 minimised: 1. Liquid soap, paper towels and foot operated pedal bins must be provided in all areas where personal care is provided. 2. The malodorous smell must be removed from the room identified during the site visit. To ensure residents are 10/07/08 protected from health and safety risks: 1.COSHH assessed items must be kept locked when not supervised. 2. Electrical safety equipment storage must be kept locked. The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 27 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 OP1 Good Practice Recommendations The statement of purpose should be reviewed to include information on how the home intends to meet the stated aims and objectives and to provide more detail of the service provided to people with dementia. Residents should have opportunities for more entertainment and outings to promote their quality of life. Locks should be provided on residents’ doors unless their risk assessment states otherwise. Receipts of expenditure should be maintained to ensure residents’ financial interests are protected. 2. 3. 4. OP12 OP24 OP35 The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 The Mellows DS0000059391.V367082.R01.S.doc Version 5.2 Page 29 - 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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