Inspection on 05/05/05 for The Mellows

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 21/10/05

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 Alan Thompson Final Report Unannounced 5th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Mellows Address 38, Station Road Loughton Essex IG10 4NX 0208 508 6017 0208 508 4649 vinod@aol.com The Mellows Limitied Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant Care Home Twenty Three (23) Category(ies) of Demetia - over 65 years of age (8), Old age, not registration, with number falling within any other category (23) of places The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 23 persons) 2. Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 8 persons) 3. The total number of service users accommodated in the home must nnot exceed 23 persons. Date of last inspection 19th November 2004 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 I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 1100 hours on Thursday 5th May 2005. This was the first inspection of this home in the inspection year 2005/6. The content of this report reflects the inspectors findings on the day of the inspection, and from taking account of the findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Residents, staff and visitors were spoken with. Random samples of records, policies and procedures were inspected and a tour of the premises took place. All residents spoken to expressed satisfaction with the care they received and with the quality of the food and accommodation offered. Staff confirmed they received good support from management. What the service does well: What has improved since the last inspection? What they could do better: Staff recruitment records need to include evidence of all required checks. Electrical equipment requires testing. Bathing facilities and some communal areas of the premises would benefit from improvement. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 6 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 I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 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 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 I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 9 Emergency admissions were avoided wherever possible. Residents in the home at the time of this inspection confirmed that they were able to visit before they moved in. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 10 Individual plans of care were in place. These contained daily actions required from staff. Internal reviews of care plans had been recorded. Discussions with residents indicated that staff treat them with respect, paying attention to their privacy and dignity when providing personal care support. EVIDENCE: A random sample of residents’ care plans were inspected. Formats included individual personal and background information, next of kin details, observations, a dependency profile covering mobility, speech/communication, sociability, bathing, continence, pain, dressing, oral hygiene, pressure sore, breathing, feeding, bowels, orientation, preparation of food, hearing, memory, tolerance, eyesight, mood. A separate assessment of specific needs was also included covering headings of sleep routines, personal cleansing, dressing, mobility, eating and drinking, elimination, work & play, vision, hearing, dentures, orientation. From these a daily plan of care had been compiled with headings of: problem/needs/actions for staff, and the expected outcomes, with an evaluation of the actual outcome. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 11 All care plans seen had been reviewed by staff. Included in care plans were risk assessments covering mobility, continence and pressure sores. Residents spoken with confirmed that they regard staff do respect their privacy and dignity when providing personal care support. They also confirmed that they were completely satisfied with staff attitudes. Interaction between staff and service users during this inspection was observed as relaxed and friendly, with staff displaying appropriate awareness and understanding towards individual needs. A payphone was available for residents to use and the inspector was advised that some choose to have private telephone lines in their rooms. Residents spoken with confirmed that they wear their own clothes. The acting manager confirmed that medical examinations and treatments were provided in the resident’s own room. The home’s written policy and guidance to staff regarding respecting residents privacy and dignity was available for inspection. This gave clear guidelines/expectations to staff on this issue and forms part of the home’s induction package. Relatives spoken with also confirmed that they were satisfied with staff attitudes. Whilst touring the premises the inspector noticed that the door lock was missing from one of the toilets, (room number 43). The deputy manager confirmed that this was scheduled for replacement. There is a recommendation on this issue in this report. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 13 A range of activities had been offered in the home each day, this included opportunities for community contact and religious observance. Visitors are made welcome, with the request that mealtimes are avoided if possible. Some residents receive visitors every day. EVIDENCE: Certificates of attendance were available to confirm that senior staff have received training regarding providing activities for residents, including those with dementia. Daily activity records had been maintained and recorded the following activities offered to residents: reading, reminiscence, painting, music and dance, chair keep fit, pat the dog, videos, manicures, crafts, karaoke, art, singing and games. A therapist visits the home regularly to provide private massage to interested residents. Residents said they were offered inclusion in activities and that the range of options suited them. Discussions with visiting relatives confirmed that they are made welcome by staff, and may meet with the resident in private. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 13 The acting manager confirmed that staff would respect residents’ wishes regarding whom they do and do not see. Community contact is maintained by some residents, who choose to attend local clubs, and receive visits from the mobile library and local church ministers. One resident attends church in the community. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home’s complaints procedure allowed for residents and relatives to formally raise any concerns. Residents and visiting relatives said they knew who to speak to if they had any issues about care or services in the home. EVIDENCE: The home’s complaints procedure was inspected, included was information on the complaint process/procedure, with timescales for expected response from the home and contact details of the regulatory authority and relevant social services departments. Evidence was available to confirm that any complaints received will be recorded and formally responded too by management in the home. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-26 The home was generally comfortable and mostly well maintained, although some communal areas were scheduled/ready for repair/redecoration. Residents outdoor space to the rear of the property was accessible. There were sufficient numbers of toilets but the assisted bathing facilities would benefit from improvement. Private accommodation was clean and looked comfortable. EVIDENCE: The home was clean, tidy and generally well maintained. Although the area of water damaged ceiling in the lounge had still not been fully repaired and some of the dining room chairs had flaking/chipped paint. There are recommendations regarding these items in this report. There was also an area of wall in WC room number 43 that was in need of repair following water damage. There is a requirement on this issue in this report. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 16 The deputy manager now keeps a written record of items/areas of the home requiring repair and maintenance. The acting manager advised that she was soon going to devise a maintenance schedule/plan for the home. 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, one provided assisted bathing facilities. There should be an improvement to this ratio and there is a recommendation to this effect in this report. There was a portable hoist, although this would not fit into either of the bathrooms with no assisted facilities. The inspector was advised that plans are in hand to convert one of the bathrooms into a ‘walk-in’ seated shower room, which would meet the recommendation. 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. The heating was off in the bedrooms and some were cool. Staff on duty confirmed that the heating is on in all rooms in cold weather and when residents wish to use their rooms during the day heating is provided. Residents and visitors spoken with did confirm that the home is warm enough. This issue will be checked again at the next inspection. 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. Residents and visitors spoken with said they found the home to be always clean and tidy. 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 I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Care staffing numbers on duty at the time of this inspection met the required levels. Recruitment procedures aimed at safeguarding the protection of residents had not been followed. EVIDENCE: Daytime staffing has been increased to a minimum of four carers on duty on daytime shifts, (however see note below regarding staff undertaking cooking duties). 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 inspector had been unaware of this change in staffing policy. Staff spoken with said they agreed to undertake cooking duties and residents said that the food provided was satisfactory. This issue will be kept under review at future inspections. Staff recruitment files inspected evidenced that application forms are completed, interview notes kept, proof of identity was obtained and criminal records checks undertaken. References were requested, however one file seen did not contain any references. There is a requirement on this issue in this report. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 18 Staff spoken with confirmed that they underwent induction and received terms and conditions of employment. The codes of practice for social care workers had been issued to all staff. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 37 & 38 There is still an acting manager in post. The management approach encouraged an open inclusive working environment. Not all records required to be kept were up to date. Staff training provided included the appropriate health and safety statutory and good practice subjects required. The acting manager was aware of the importance of ensuring that the home was safe for residents and staff, however update testing of electrical appliances and supply was needed. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 20 EVIDENCE: There was still no registered manager in place. The temporary arrangements concerning the day to day management of the home, (the company secretary has assumed the role of manager pending appointment), continue and did not appear to be causing any detrimental effects on the running of the home. The acting manager has previous management experience relating to the role and was nearing completion of the Registered Managers Award. Application to the CSCI is still required by regulation and there is a repeat recommendation on this issue until a manager is appointed. Random samples of records required to be kept were inspected. These included: fire drills, staff rota, care plans, assessments, visitors book, regulation 37 notices, background information and next of kin details, staff recruitment records, complaints and accident records. Staff recruitment records were not in order. There is a requirement regarding 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/maintenance certificates were available for inspection to confirm that the home’s gas supply, fire alarms & equipment, hoists and passenger lift had all been tested/serviced within recommended timescales. The electrical installation supply test had expired in March 2005 (test required every 5 years) and there were no records of electrical portable appliance testing having taken place. There are requirements on these items in this report. The hot water supply was regulated for delivery at or near a temperature of 43°C, (not tested). Risk assessments were now in place for the premises and all assessed working practices. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 x x x x 2 2 The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 23(2) Requirement The registered provider must make arrangements for the area of water damaged wall in wc number 43 to be repaired and made good. The registered provider must ensure that staff recruitment records include at least two written references. The registered provider must make arrangements for the homes electical installation supply to be tested by appropriate contractors. The registered provider must make arrangements for the testing of all portable electical applicances in the home. Timescale for action 31/7/05 2. 29 & 37 19, schedule 2 13(4) 31/5/05 3. 38 31/8/05 4. 38 13(4) 31/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 10 19 Good Practice Recommendations The registered provider should arrange for the missing door lock on wc number 43 to be refitted/replaced. The registered provider should ensure that repairs to the I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 23 The Mellows 3. 4. 5. 19 21 31 ceiling panels in the lounge are completed. The registered provider should consider replacing/repainting the dining room chairs that had flaking/chipped paint. The registered provider should ensure that the ratio of assisted bathing facilties in the home is increased. The registered provider should ensure that a permanent manager is appointed and application is made to the CSCI for registration. The Mellows I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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 I56 I05 S59391 The Mellows V226483 UI 5.05.05 stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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