Inspection on 30/05/06 for The Mellows

This inspection was carried out on 30th May 2006.

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Mellows 38 Station Road Loughton Essex IG10 4NX Lead Inspector Neal Wolton-Harragan Key Unannounced Inspection 30th May 2006 10:20a 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.V297319.R03.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.V297319.R03.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 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.V297319.R03.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 8 persons) The total number of service users accommodated in the home must not exceed 23 persons 21st October 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.V297319.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced key inspection at the Mellows, the first inspection of the home for this inspection year. During this inspection, 23 of the 38 standards were looked at; nineteen were met, three were almost met (minor shortfalls) and one standard was not applicable. This has resulted in 2 requirements from this report. This inspection consisted of discussions with the acting manager, the acting care manager, three staff members, five service users and one visiting relative of a service user. It also involved a tour of all areas of the home along with the examination of records. Mrs Patel, the acting Manager, has completed the NVQ level 4 Registered Managers award and is in the process of completing an application to the Commission for Social Care Inspection for registration as the manager of The Mellows. What the service does well: What has improved since the last inspection? What they could do better: The temperature of hot water at the Mellows was of concern as it was far in excess of 43˚C. Mrs Patel gave assurances that this would be attended to immediately although as yet this has not been confirmed by the home as being addressed. The Mellows should improve the way individual care plans are written because at this visit these plans did not clearly detail how the assessed needs of the The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 6 individual should be met or the actions required from staff to support the service user. 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.V297319.R03.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Service users had their needs assessed prior to moving into the home and were assured that these would be met. The home did not provide intermediate care. EVIDENCE: Examination of service user records showed that service users needs were adequately assessed prior to admission to the home. Part of this information came from the COM5 received from the referring social work team and is supplemented following a visit to the prospective service user, by a senior member of the care team, either at home or in hospital. Discussions with staff an examination of records showed that the home did not provide intermediate care and therefore this standard was not applicable. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The health, personal and social care needs of service users were set out in individual plans of care although these require greater detail. Health care needs of service users were adequately met and service users felt they were treated with respect. No service users were responsible for their own medication at this inspection. EVIDENCE: Records relating to four service users were sampled and all had individual plans of care. However, these lacked detail as to how the assessed needs of the individual should be met or the interventions required from staff to support the service user. The plans were reviewed at monthly intervals although these reviews appeared to function more as monthly summaries than details of revised care needs. The registered person must ensure that the identified needs of individual service users are clearly identified along with detailed plans as to how these will be met. The health care needs of individuals were identified and the services of healthcare professionals were brought into the home as required. District nurses visited the home on a regular basis to provide nursing services to residents’, including the treatment and redressing of pressure sores. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 10 Service user records and discussions with the acting Care Manager showed that no service users took responsibility for their own medications at the time of this inspection. The home’s medication policy and procedure protected the service users and these were appropriately applied. All medications were appropriately stored and only administered by those trained to do so. There were no gaps within the medication administration records at this inspection. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 11 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): 12, 13, 14 & 15 The lifestyle experienced within the home largely matched the expectations of service users and service users were able to maintain contact with family and friends as they wished. Service users were supported to exercise control over their lives. Service users were offered a wholesome, appealing balanced diet. EVIDENCE: The examination of records showed that there was a programme of regular activities although there was no recorded evidence of this programme being followed. Records and discussions with staff and service users showed that service users were able to maintain contact with family and friends with many receiving regular visitors at the home. The home held service user meetings at approximately 6-week intervals at which issues such as meals and activities were discussed. The Mellows does not have a dedicated cook; this role is assigned on a daily basis to a member of the care team. This did not appear to have diminished the quality of food offered and there were adequate numbers of carers available to allow this without reducing the quality of care to service users. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 12 Nutrition records were maintained and showed that a good range of meal choices was offered. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Service users felt safe at The Mellows and there were adequate arrangements in place to help protect service users from abuse. EVIDENCE: The Mellows had a robust and accessible complaints procedure that was supported by appropriate Protection Of Vulnerable Adults protocols and the Essex Vulnerable Adults guidelines. Service users spoken with felt safe at the home and indicated that they felt they could raise issues of concern with the proprietors and these would be acted upon. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home was largely safe and generally well maintained. The home was mainly clean, pleasant and hygienic. EVIDENCE: An environmental tour gave evidence that the home was largely safe and well maintained. There were a number of minor repairs required and these were fed back to the acting Care Manager during the tour and to the acting Home Manager at the end of the inspection. The principle area of concern was hot water being delivered at baths at temperatures in excess of 60ºC and this required immediate attention. There were some odours noticed in some areas during the inspection. However, these had been eradicated by the end of the day and the Inspector was able to form the belief that hygiene and cleanliness was appropriately maintained. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Staffing levels and skills appeared to meet the needs of those living at The Mellows and kept service users safe. The selection and recruitment policies and practices served to support and protect service users and staff were provided good induction and training opportunities to ensure competency in undertaking their roles. EVIDENCE: Records examined at the home showed that The Mellows was appropriately staffed to meet the needs of those living there. Additional staff were rostered for cleaning, maintenance and administrative duties. Care staff took turns in cooking duties designated on a daily basis. Staff had a good understanding of their roles and the needs of the service users. Staff files also showed that there was a programme of induction and mandatory training as well as a schedule of ongoing training and development for all staff. All carers at The Mellows had completed training to care for people with dementia and Mrs Patel, the home’s acting Manager, has completed an NVQ level 4 award. Staff files sampled showed that all appropriate pre-employment checks had been conducted and all required records were maintained. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 The home was appropriately managed by an acting Manager and was run in the best interests of the service users. Procedures at the home ensure that service users financial interests were safeguarded. The policies, procedures and practices at the home largely promoted and protected the health, safety and welfare of service users, staff and visitors. EVIDENCE: Records and discussions with staff gave evidence that the home was being appropriately managed and in the best interests of the service users. There were regular service user meetings and staff meetings all of which were recorded. A quality audit was conducted annually through the collation of questionnaires distributed to, and received from, service users, relatives and other stakeholders of the service. Mrs Patel has completed the NVQ level 4 Registered Managers award and is in the process of completing an application The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 17 to the Commission for Social Care Inspection for registration as the manager of The Mellows. Policies and procedures showed that the financial interests of service users were protected. The acting manager reported that the home does not get involved in individual service users’ finances but do hold small amounts for incidental expenses. Records for these were sampled and all were appropriately maintained. The health, safety and welfare of service users, staff and visitors were largely protected. However, there was concern that the hot water to baths was delivered at temperatures exceeding 60ºC. The acting Manager gave assurances that this would receive immediate attention. The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 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 3 3 X 3 X X 2 The Mellows DS0000059391.V297319.R03.S.doc Version 5.2 Page 19 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 OP7 Regulation 15 Requirement The registered person must ensure that the identified needs of individual service users are clearly identified along with detailed plans as to how these will be met. The registered person must ensure that hot water is delivered to baths at around 43˚C. Timescale for action 01/09/06 2. OP19 OP38 13(4)(a) & (c) 30/05/06 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.V297319.R03.S.doc Version 5.2 Page 20 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.V297319.R03.S.doc Version 5.2 Page 21 - 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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