Inspection on 21/10/05 for The Mellows

This inspection was carried out on 21st October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Mellows 19/06/08

The Mellows 19/06/07

The Mellows 30/05/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Mellows 38 Station Road Loughton Essex IG10 4NX Lead Inspector A Thompson Draft Report Unannounced Inspection 21st October 2005 11:00 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 The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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.V260561.R01.S.doc Version 5.0 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) 01708 758296 The Mellows Limited Manager post vacant Care Home 23 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (23) of places The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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 8 persons) The total number of service users accommodated in the home must not exceed 23 persons 5th May 2005 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 rooms. 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 Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This pre-notified inspection, although still treated as an unannounced inspection for the purposes of this report, took place at 1100 hours on Friday 21st October 2005. This was the second inspection of this home in the inspection year 2005/6. The content of this report reflects the inspector’s findings on the day of the inspection, and from taking account of relevant findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Residents and staff were spoken with. There were no relatives available to speak with, but questionnaires were left at the home so that they had the opportunity to make their views on the service known to the Commission. Random samples of records, policies and procedures were inspected and a tour of the premises took place. All residents spoken to, who were able to express an opinion, said they were satisfied with the care they received. Most said they were also satisfied with the quality of the food and accommodation offered. Staff confirmed they received support from management. They also confirmed that they had been offered NVQ training. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Staff responsible for administering medication to residents’ need to ensure that records are always fully up to date. ------------------------- 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 Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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 The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 The home’s assessment format and process was adequate for ensuring that initial perceived needs were identified upon admission. Anyone considering moving into the home may visit to meet residents and staff, and to view facilities, to enable them to assess the suitability of the service. EVIDENCE: The acting manager and deputy manager advised that senior staff visit prospective new residents at home or in hospital to undertake a preassessment of need. The format used was unchanged since the last inspection and included headings covering: personal information, next of kin, GP, medication, physical state, pressure areas, mental state, diet and fluids, likes, dislikes, communication, mobility, elimination, activity and recreation, personal cleansing, dressing, oral hygiene, religious needs, finances, plus other relevant information. Prospective new residents and their representatives are encouraged to visit the home prior to making a decision to move into The Mellows for a trial stay. Meals were available for the resident during these visits. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 9 The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 & 10 The health care needs of residents were generally assured. The home’s medication procedures, practices and staff training appeared to provide adequate guidance for dealing with medicines, however administration records were not all up to date. EVIDENCE: Residents’ personal and oral hygiene needs are recorded in the homes assessment format and individual care plans. District nursing services provide tissue viability advice to staff, and guidance/advice on continence issues, recognition and treatment of pressure sores. District nurses will also visit the home to provide nursing services to residents’, including the treatment and redressing of pressure sores. Equipment for the promotion of tissue viability and prevention or treatment of pressure sores is also provided by district nursing services. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 11 Chiropody, optician, and dental services are provided in the home (by visiting practitioners), or residents may use community based facilities. New residents may retain their own GP (if possible) or a local practice is used. A record is kept on all residents of GP reviews. This is to ensure that all are seen regularly. Nutritional advice is accessed via the GP, as is access to hearing tests at a local hospital. Psychiatric nurse support is available. The home’s medication policy was unchanged since last inspected. Included in the policy was guidance and instruction to staff on the receipt, administration and return of unused medication. Medication administration records and records of unused medication returned to the pharmacist were seen. Generally these were acceptable, however there were two gaps on one sheet. Responsible staff must ensure that all prescribed dosages are accounted/signed for. There is a requirement on this issue in this report. The home’s pharmacist provides close support and advise on the re-ordering, delivery and storage or medication supplies. The pharmacist also provides training to staff on medication issues. Certificates of attendance were seen and included areas covered as: what medicines are, labelling, types of medication, homely remedies, handling, side effects and special considerations. The deputy manager advised that update training was due to take place. At the time of this inspection no residents administered their own medication. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 – 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 &15 Residents were supported in exercising choice regarding day to day routines in the home. The home caters for residents preferred choices of menu. Food seen was well presented and appealing. EVIDENCE: At the time of this inspection two residents managed their own financial affairs. Personal possessions brought into the home on admission were recorded. Information on independent advocacy services was available, this had been offered to one resident who has no family support. Most residents spoken with who expressed an opinion said they were satisfied with the food provided. A new procedure on cooking had been implemented since this standard was last inspected. This has dispensed with the employment of a designated cook/chef and instead involved other staff taking turns (by agreement) in taking on cooking duties and responsibilities. This arrangement had not appeared to have had any negative effect on the standard, choice and quality of food. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 13 The deputy manager was responsible for ensuring food stocks were adequate, and that provision of supplies met with planned menu need. The inspector was advised that menus are based on the likes and preferences of residents, and that discussion on food and menus had been included at the monthly residents meetings. Nutrition records had been maintained, these were detailed and evidenced choice of menu. The main daily meal was lunch, teatime meals were a hot or cold alternative. Supper snacks were provided to those who required one, these would usually be toast or a sandwich. Drinks were available at all times. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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 the following standard(s): 18 The home’s adult protection policies, procedures and practices were aimed at ensuring residents welfare. EVIDENCE: The home’s own policy and guidance regarding abuse and adult protection is comprehensive. This included clear definitions on: types of abuse, indicators, why abuse happens, patterns of abuse, taking action, referrals, and on responding to and recording suspected incidents/allegations of abuse. The home also had the latest Essex Social Services guidelines and procedures relating to adult protection and actions expected from staff under this subject. Included were recording and reporting templates and procedures along with definitions of the various recognised types of abuse. Also in place were the Department of Health’s POVA (protection of vulnerable adults) guidelines issued in July 2004, and the Essex Vulnerable Adults Protection Committee (EVAPC) reporting/alert forms. The deputy manager provides in-house training to staff since she achieved the status of POVA trainer, (through Essex County Council). The home’s ‘whistleblowing’ statement/policy met the standard. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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 the following standard(s): 19,20,21,23,24,25,26 The home was generally comfortable and mostly well maintained. Residents outdoor space to the rear of the property was accessible. There were sufficient numbers of toilets, and assisted bathing facilities had been improved. Private accommodation was clean and looked comfortable EVIDENCE: The home was clean, tidy and generally well maintained. Since the last inspection one bathroom on the groundfloor had been converted into a ‘walkin’ shower, the area of water damaged ceiling in the lounge had been fully repaired and the dining room chairs had been revarnished. The acting manager advised that internal redecoration and refurbishment of private rooms is continuing, evidence of this work was seen on the day. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 16 The water damaged area of wall in wc number 43 had not yet been repaired, however all wc’s are now scheduled for refurbishment. Progress on this will be checked at future inspections. The deputy manager keeps a written record (seen) of items/areas of the home requiring repair and maintenance. The acting manager reviews this and approves appropriate action and repair. The garden was accessible by ramp. The Mellows is located close to the centre of Loughton with shops and amenities. There is one large communal lounge/dining room for residents’ use. The home has three communal bathrooms, two now provide assisted bathing facilities (one bath and one shower). This is an improvement since the last inspection and fully met the recommendation made in the last report. There is a passenger lift, and grab rails were fitted in toilets and communal rooms. Private bedrooms inspected were clean, and had been personalised to individual taste. Residents spoken with confirmed that the home is warm enough. Radiators seen in bedrooms were guarded and had temperature adjustment control. Hot water is regulated for delivery at or close to 43 degrees celcuis, (not tested). Emergency lighting is fitted throughout the home. The laundry was located away from any food preparation areas and was equipped with hand washing facilities for staff and washing machines with appropriate temperature programmes and sluice cycles. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 30 Staffing levels and skills appeared to meet the needs of residents. Staff were provided good induction and training opportunities to ensure competency in undertaking their roles. EVIDENCE: Daytime staffing has been maintained at a minimum of four carers on duty, this included provision for staff undertaking cooking duties. Weekday shifts also comprise of (in addition to the above numbers), the deputy and acting managers. Who also take turns in being ‘on-call’ at weekends. Night staffing remains at two waking carers. Additional staff were rostered for cleaning, maintenance and administrative duties. Care staff took turns in cooking duties. The requirement in the last report for two written references to be obtained for all new staff had been met. Staff training records evidenced that staff had received training in: numeracy & literacy levels 1 & 2, food hygiene (update scheduled for the week following this inspection), abuse, dementia, first aid, manual handling, tissue viability, infection control, prevention of falls, age discrimination, electrical testing, reminiscence therapy, health & safety, fire drills, medication. Manual handling update training was due. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 18 Two staff were on NVQ level 3 (national vocational qualification) training, four were on NVQ level 2 courses. The acting manager had achieved the Registered Manager award and the deputy manager had commenced this training. The acting manager had also achieved the Diploma in Performance Coaching qualification. New staff employed over the past year confirmed that they had induction training and were expecting to be offered NVQ training when possible. The home’s induction format was inspected. This included headings of health & safety, fire, contacts, job description expectations, care plans, reports, infection control, layout, equipment, values of care and service provision, worker relationships, communication, confidentiality, role of the worker, service user groups, needs of the resident, personal hygiene, eating, drinking, continence, responding to these needs, manual handling, emergency aid, fire safety and food hygiene. Senior staff work with new staff on all these areas and record competencies. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,37,38 Appropriate procedures for gaining the views of residents had been fully implemented. Residents’ financial interests appeared to have been safeguarded. Records required by regulation were in place, but not all were fully up to date. The management approach encouraged an open and inclusive working environment. The health, safety & welfare of residents and staff was generally assured. The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 20 EVIDENCE: There was still no registered manager in place however the acting manager has now requested an application for registration with the Commission. This met the recommendation made in the last report. The home’s quality assurance questionnaire had been circulated to residents. The format included seeking views on food, personal care, daily living, premises, and management. Records of responses were available for inspection along with a summary of findings. It is expected that this process will occur at least annually. A discussion took place regarding the benefits of circulating a separate questionnaire to relatives. Monthly residents meetings are also held in the home. There is a set agenda for each meeting covering areas of: food, care, living, premises and management. Minutes had been kept of discussions and decisions made. Two residents were managing their own financial affairs. Relatives provide this type of support to the remaining residents. At the time of this inspection no residents monies were being held for safekeeping by the home. Any expenditure incurred on behalf of residents is billed to relatives. Records of personal items brought into the home on admission were recorded in individual files. Random samples of records required to be kept were inspected. These included: fire drills, staff rota, visitors book, regulation 37 notices, accident records, medication records, nutrition and fire procedures. All were in order except medication records, there is a requirement on this in this report. Staff training records confirmed that training courses are provided in moving and handling, fire safety, first aid, food hygiene, health & safety and infection control. COSHH (Control of Substances Hazardous to Health) assessments are held in the home. Test certificates/maintenance records were available for inspection to confirm that the home’s electrical installation supply and portable electrical appliances had been tested within required timescales. This fully met the requirement made in the last report. The hot water supply was regulated for delivery at or near a temperature of 43°C, (not tested). The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X 2 3 The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 22 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 9 Regulation 17, schedule 3 Requirement The registered provider must ensure that records of medication administered to residents are kept up to date. Timescale for action 31/10/05 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 The Mellows DS0000059391.V260561.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Mellows DS0000059391.V260561.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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