Inspection on 10/11/09 for The Mount

This inspection was carried out on 10th November 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mount 05/12/08

The Mount 17/04/07

The Mount 05/07/06

The Mount 15/12/05

The Mount 04/10/05

The Mount 16/11/04

The Mount 22/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 The Mount Wood Lane Yoxall Staffordshire DE13 8PH Lead Inspector Mandy Brassington Key Unannounced Inspection 10th November 2009 08:15 The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service The Mount Address Wood Lane Yoxall Staffordshire DE13 8PH 01543 472081 F/P 01543 472086 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) Rebecca Homes Ltd Paul Challinor Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disabiltiy (LD) 7 Mental Disorder (MD) 7 The maximum number of service users to be accommodated is 7. 2. Date of last inspection 5th December 2008 Brief Description of the Service: The Mount is a residential home located on the outskirts of the village of Yoxall, Staffordshire. There is a shop, post office and pub within the village: other services need to be accessed through public transport or the use of a vehicle. There are a variety of local walks around the home where people can enjoy the benefits of living in a rural environment. The home provides a service for people who have a learning disability or a mental disorder. The large detached house is set in extensive grounds; stables on the site have been converted into a sensory and computer room. The home offers seven single bedrooms, three provide and en suite facilities. People have access to a lounge, separate dining and relaxation room. There is an indoor swimming pool, though this is currently not in use. The fees charged for the service provided at The Mount as recorded in the Service user Guide are £1,348.00p per week with an additional cost per hour for a one to one service. These fees applied on the day of our visit, the reader may wish to contact the service for up to date information. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered the core Standards. The inspection took place over 11 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. The focus of inspections we undertake is upon outcomes for people who use the service and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, standards of practice and focuses on aspects of service provision that need further development. The manager completed an Annual Quality Assurance Audit (AQAA) for us. There were questionnaires sent to people who use the service, and professionals. On the day of the inspection, the home was accommodating four people. We, the commission examined records, carried out indirect observation of four people who used the service and four staff on duty. Three plans of care and three staff records were examined and observation of daily events took place. Information relating to the service and how it is managed including investigations into complaints were inspected. We spoke with all people who use the service, the manager, Business Manager and three staff on duty. We looked at three bedrooms, the communal lounge areas, and bathing facilities. We inspected the storage system and medication procedures. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: People are able to spend time in the home before making a decision to move in and talk to other individuals and staff. Each person living in the home has a care plan so that staff know how to support them to meet their needs and goals. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 6 Staff ask the people what they want to do, where they want to go, what they want to eat and drink and how they want to spend their time. People dress in their own style and if they need support, staff help with personal care. Individuals are well-presented and encouraged to take a pride in their appearance. Staff like to develop good relationships with people and will spend time talking and taking an interest in peoples lives and adventures. Staff have a good knowledge of the care needed and what people may want. Staff make sure that people get the medication they need when they need it to help to meet their health needs. Each person has their own bedroom that is decorated in the way they want it to be. They have the space in their bedroom to keep their personal things. A monthly visit is carried out by a senior manager to check whether people are happy in the home and can do the things they want to do, whether information is available so staff know how to provide support and care and if the home is clean and tidy. What has improved since the last inspection? What they could do better: Care plans should be reviewed to ensure people who use the service can contribute towards them and understand what is written and how they can expect to be supported. The staffing provided needs to reflect the service people have agreed to receive. This will enable people to be supported to do all agreed activities in their plan and be able to spend time in activities of their choosing on a one to one basis. Where handwritten additions or amendments are made to medication administration records these should be checked and signed by two staff to help make sure they are accurate and reduce the risk of errors. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 7 The management team and staff need to be aware of safeguarding procedures and the importance of accurate recording. This means that people can be confident that any agreed outcomes are based on actual events to ensure people are not vulnerable. Where limitations on peoples liberty are carried out, it must only be done if it is in peoples best interests. The Mental Capacity Deprivation of Liberty safeguards ensure that people can make a decision about whether this is right. The staff need to ensure they know about this law and carry out any potential deprivation of liberty in a way that protects and safeguards people. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can decide whether the care home can meet their support and accommodation needs. This is because people can visit the home and get information about the service. The information is available using pictures to explain the service provided and help people to understand. EVIDENCE: Since out last visit, one person has moved to the service from another home within the company. Discussion with staff and the person who uses the service revealed that the individual had chosen to move to the home for personal reasons. The individual already had a good relationship with staff and other people living in the home. The decision to stay here was being kept under review to ensure the person was happy and wanted to remain there. The AQAA recorded that for new referrals, where possible an interim visit is arranged after an assessment. The assessment is carried out to ensure the suitability of the service and how people would be supported within the shared The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 10 living environment. The AQAA recorded that the views and support of people already living in the home would be taken in to account. We looked at two records which demonstrated that the assessment process also included a single assessment completed by a Care manager from the Placing Authority. The home has developed a Statement of Purpose and Service User Guide which records the service provided and fee levels. The registered person needs to ensure this is kept up to date to reflect the actual service provided in relation to staffing and facilties. At the time of the visit, the Swimming pool had been out of use for a significant period of time and there was no date for this to be available. The Service User Guide also recorded that people were able to receive one to one support in addition to the basic funding, and the Registered Person agreed it was not clear how this was provided. The Guide needs to reflect accurate information regarding fee levels and the service provided. The Service User Guide is available in pictorial format which means people are able to gain a better understanding of information about the service. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to benefit from staff having information about how to provide support and care. Plans should to be in a style people can understand, so they can be involved in their care planning. EVIDENCE: We looked at the support and care plan for three people; a support plan tells staff about a persons needs and how to meet them. The plans contain detailed information for staff about peoples needs and their support. An example is, one plan contained information about how to support a person with complex needs; the plan recorded sample questions to ask to use in diversion The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 12 methods, and how staff are not to use negative words such as no or stop. This plan was discussed with staff, who were aware of the content and demonstrated a good knowledge of how to support the person and work as a team to resolve any issue. The support plans we looked at show they are reviewed, though the plans are large and some information was not easily accessible or in other folders. All relevant information should be easily accessible to ensure people are appropriately supported and all staff are aware of any review. The AQAA recorded that symbolised pre-review documentation is completed to find out the individuals aspirations, goals and who they would like to attend their review meeting. On the day of our visit, a review was being planned and we saw this included a review of all incidents and events in the home. One plan contained information that had been written with the person using the service. The plan was written in the first person and contained pictures and photographs to support understanding, including a photograph of events to show how the person manages stressful situations. This means the person has been able to contribute to the plan and is written in a way they understand. The Plans of care were discussed with the registered person as two of the plans we saw did not include contributions from people who use the service and did not support people to be involved in their care planning. It is recommended that the plans are developed to ensure they provide detailed information in a format people can understand, so individuals can be involved in their care planning. Care records contain assessments of risk. This should promote peoples independence and ensure their safety whilst doing so. For example, one assessment of risk records that a person may eat unhealthily to manage stress. An assessment regarding the persons mental capacity has been completed and recorded that they had capacity to make decisions about what they should eat. Therefore a plan had been agreed with the person as to how they would be supported to eat a healthy diet and manage individual finances. The Statement of Purpose records that individuals are able to be involved in developing skills needed for independent living. People did not have specific plans of care and a record of the opportunities to develop skills and what support was required was not available. This means that people may be receiving different opportunities and experiences and does not support consistent person centred care. Records included how people are supported to make choices and decisions about their lives. Some people are able to use a key to their bedroom and two people spoken with stated they had a key to their room. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 13 People were observed to make choices during the day about what they did, where they went and what they ate. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16, 17. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to engage in activities of their choosing, though the staffing provided means people do not always receive additional contracted hours to enable them to receive one to one support. EVIDENCE: On the day of our visit all four people were resident in the home and two staff were on duty. During the day people were observed going shopping in the local town and collecting prescribed medication, spending time in the internet café within the grounds, listening to music completing puzzles. Each person has a weekly planner, which records daily activities. We looked The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 15 at the week of our visit and the previous week within three plans, and found that people are not always involved in the planned activities and some plans are repeated on a weekly basis. For two plans, the daily records and the activity planners do not clearly record the activities a person has been involved in. On many shifts there were only two members of staff on duty and it was unclear how people were receiving additional paid one to one hours to provide support within the home and community. Many entries in the record sheets only recorded people were in the lounge or in their bedroom. This was discussed with the registered person as the plans did not demonstrate how people were able to choose activities and repeated activity sheets were not an example of person centred care. The registered person agreed this practice needs to be reviewed. The use of staff within the home in line with agreed contracts is addressed within the Staffing Outcome area. One person has a daily planner and is able to place details of planned activities on his board. This is carried out because it has been identified that the person likes structure and this reduces anxiety levels. Discussion with three people who use the service demonstrated that individuals enjoy spending time in the internet café in the converted stables, and spending time on the computer. One person told us they have their own money to do personal food shopping and used the computer to do internet shopping. One person said, I have my own car, its a new car I choose it. I like the colour. The person stated he is able to use the car for going out in the community. One person told us they enjoyed walking saying, its lovely here, its so quiet and there are lovely places for me to walk. I like it here in the country. The AQAA recorded that people have an opportunity to attend Mencap evening clubs three evenings a week, people have membership of a snooker club, health club, and national membership of the cinema club which allows individuals free entry to any cinema nationwide. Discussion with one person who uses the service reported that he enjoyed going to the clubs and meeting with friends and listening to the music. Care records shows peoples religion, and the registered person said people who live there do not show an interest in attending church, unless it is to celebrate religious events such as Christmas and Easter. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 16 People have their own cupboards and fridge in the kitchen and individuals are responsible for their own shopping budget. People were observed choosing lunch from the foods they had purchased. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their health needs are met to ensure their wellbeing. EVIDENCE: The people living in the home were dressed in individual styles that reflected their age, cultural background, their gender and the weather. People said that if they needed support staff would go with them to buy their clothes and individuals looked clean, and attention had been given to their personal care. Care plans recorded how people are to be supported to meet their personal care and health needs. Staff reported they were aware of how to help people maintain good health and any issues of concern in their plan of care. Records of all health appointments and the outcome of these are kept so that staff can follow the advice given to ensure health needs are met. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 18 One plan included information about diet and support required to maintain a healthy diet and maintain a suitable weight. Staff reported that certain foods are eaten in large amounts when the person is anxious and the support required is recorded in the plan of care. All medicines are stored in a locked cupboard and medication administration records are signed to show when medicines are given or refused. A medication administration record (MAR) shows people prescribed medicines, the dosage and the times it should be given to people. This should also provide an audit trail of what medicines people have taken. At the front of the persons Medication Administration Record (MAR) there is a photograph so that unfamiliar staff would know who to give the medication to. Some people are prescribed as required (PRN) medication and protocols for when and why this should be given are written in the plan of care. This information was not always clear as it was included in the support plan along with information about complex behaviour. This information needs to be easily accessible. Medication Administration Records were examined. There were no gaps in recording and the record included copies of prescriptions so that it is clear that people are getting the medication they are prescribed. An audit was carried out for three people and included old MAR Sheets, past prescriptions, the medication Returns Book, and daily notes. The registered person agreed that although all documentation was in place, it was sometimes difficult to find, making the process difficult. The registered person stated they would review this to ensure it was clear that people were receiving the right medication and could demonstrated when and why this was given. The registered person stated that the audit had highlighted areas of improvement to be made and all medicines not used would be returned to the pharmacy on a monthly basis. We saw that where medication administration directions had been handwritten on MAR charts these had not been checked and signed by two staff to make sure they were accurate and reduce the risk of errors. The registered person was not aware that this was considered good practice and revised the procedures in the home on the day of our visit. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to raise concerns and are confident their views will be acted upon. EVIDENCE: People living in the home said they knew who to speak to if they were unhappy and how to make a complaint. Individuals said that staff always listen to them and act on what they say. The complaints procedure included the information that people would need, so they knew what to do if they were unhappy with the service provided. It is available in the Service Users Guide in pictorial format. The Service User Guide also records unacceptable behaviour in the home such as bullying and how people should respect others. We have received two complaints regarding the service since our last visit and these were sent to the registered person to investigate using their complaints procedure. One complaint was examined during our visit and we saw that the registered person had recorded necessary information and responded appropriately. There have been two safeguarding investigations which remain open and subject to investigation. Staff reported they have attended training to The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 20 recognise signs of abuse and how to safeguard people. The registered person must ensure that suitable recording procedures are used, all information is accurate and all staff are aware of safeguarding practices as information relating to one safeguarding was misleading. This is further addressed in the management outcome. All staff spoken with demonstrated an understanding what restraint is and alternatives to its use in any form are always looked for. Staff have good knowledge about managing complex behaviour and how to use diversion and deescalate incidents. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable, safe, clean and homely environment that meets their individual needs. EVIDENCE: The home is a large house situated on the outskirts of a village. Each person has there own bedroom they are able to personalise to reflect their interests. Three people chose to show us their room which contained photographs and pictures and a variety of personal electrical equipment including lap tops, televisions and music equipment. Each person is able to have a key to their room. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 22 Within the grounds there is a converted stable, which has been converted to an internet café and sensory room. Both rooms had been developed to a good standard and two people reported that I love the café; I like to go on the computer. Discussion with two people revealed they were aware of how to keep safe when using the internet. The AQAA recorded that the home has a maintenance log and a rolling maintenance programme which is reviewed monthly to keep up the standard of the environment. There is a housekeeper who maintains stock levels and to clean and tidy the home along with staff and people who use the service. The home has a gardener to maintain the grounds of the home. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 36. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing provided needs to reflect the support as described in the plan of care and contract to receive the support they require. EVIDENCE: Upon arrival at the home there were two staff on duty and four people were living in the home. The manager was working in a supernumerary capacity across the morning and afternoon shifts to provide management support and complete administration duties as required. It is evident from discussion with the registered person, examination of the staff roster, Statement of Purpose, Service User Guide and Contract that people are funded for additional one to one hours. The Business manager reported that these hours have been included within the general staffing of the home. The Service User Guide states the basic core costs including all core The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 24 staffing, meaning day staff, sleep in staff and waking staff is provided within the core fees and additional one to one funding can be purchased including community support. This means one to one funding is an additional service. We carried out an audit of staffing provided for the week prior to our visit. The roster recorded that for some shifts there were only two members of staff on duty. The registered person showed us that people have a total of twenty hours one to one funding each day. The current staffing does not reflect peoples funding arrangements, which mean people are not receiving the contracted service and have reduced opportunities for personal care and support. The staffing provided also needs to reflect the care and support needs assessed within the plan of care and assessments of risk. One plan recorded that where a person exhibits complex behaviour and where restraint is required, three people need to be involved, as one person is responsible for ensuring the well-being of the individual. This was discussed with the registered person as there was not always three staff on duty. This means people who use the service and staff could be at risk of harm. It is required that the home reviews the staffing provided and ensures that the roster reflects the actual funding arrangements provided for each individual and identified plans of care. This will enable people to receive an appropriate level of support to maintain their plan of care and people will not be placed at risk. We inspected three staff records which demonstrated the service has good recruitment practices. Prior to employment, references and Criminal Record Bureau Checks (CRB) had been obtained. This means the service has carried out appropriate checks to ensure that people are suitable to work with vulnerable people. Staff said they had an induction when they first started working there that included training, reading care plans of the people who live there, policies and procedures and shadowing other staff. This lasted for about three to four weeks depending on the individuals previous experience. A copy of any training staff had attended is available for review. Discussion with staff on duty revealed they had been able to attend training to learn about and understand autism and managing complex behaviour. One member of staff demonstrated a very good understanding of peoples needs and support. The staff talked about how the team used the information within the plans of care to ensure people were supported with complex behaviour in a way to reduce risk of harm. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be generally confident that the management arrangements ensure the home is run to keep people safe, although further development is required to ensure all people are safeguarded through procedures in the home and staffs knowledge. EVIDENCE: The AQAA recorded that the Registered Manager has a National Vocational Qualification Level 4, has obtained the registered Managers Award and has many years experience in differing care environments. If this training is put The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 26 into practice people should be confident the home will be run in a way that meets their needs. Monthly visits are carried out by the Business Manager. These visits involve talking to people who use the service, staff, looking around the home and records. We saw reports of these visits, which showed support plans, the environment, staff training records, the environment and hygiene were looked at. It also shows what the service does well and areas that need improving. Meetings are held with people who live in the home, giving individuals an opportunity to have say in how their home is run. The manager said people are able to choose what to talk about and are supported to air any views. The manager is aware of the need to promote health and safety and recorded in the AQAA that a Health and safety officer is in place to ensure all aspects of health and safety is monitored, and with pro active working they ensure the service is up to date with current legislation and practices. It was highlighted during one safeguarding investigation that key pads had been fitted on internal ground floor doors to limit access for one individual. This was discussed with the Manager and Business Manager that this could represent a deprivation of liberty and an application should have been made under the Deprivation of Liberty Safeguards procedure as requested by the placing Authority. On the day of our visit, these had been disabled as the person was not in the home. The registered person confirmed an application had not been made as required to the Local Authority. The Business manager stated they would be removed. The registered person must ensure that the Mental Capacity Act Deprivation of Liberty safeguards are well known and understood by all staff. The registered person is required to demonstrate to us how they will ensure that the law will be met in the future to ensure people are safeguarded and their liberty is not deprived without authorisation. One recent safeguarding incident resulted in a police investigation due to incorrect information from the service; this did not lead to any prosecution due to misinterpretation of information presented to the safeguarding team by the registered person. The registered person must ensure that all information obtained is recorded and interpreted correctly to safeguard people living in the home. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Version 5.3 Page 28 The Mount DS0000028634.V378389.R01.S.doc 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 YA33 Regulation 18 (1)(a) Requirement Where people are receiving a contracted service for additional hours for support, this is to be provided as agreed. Timescale for action 10/12/09 2 YA42 13 (6) It is required that the staffing provided in the service be reviewed to reflect the agreed contract so that people can receive agreed support and care. 11/01/10 The Mental Capacity Act Deprivation of Liberty safeguards need to be well known and understood by all staff. The registered person is required to demonstrate to us how they will ensure that the law will be met in the future to ensure people are safeguarded and their liberty is not deprived without authorisation. The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 29 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 3 Refer to Standard YA1 YA6 YA6 Good Practice Recommendations The Statement of Purpose needs to be kept up to date and the service and facilities to ensure people are aware of the service provided. Care plans should be developed in a format that people can understand and contribute towards, and is meaningful to that individual. All current information about peoples assessed needs and support needs to be easily available to staff and people who use the service to ensure up to date consistent information is available to support people. To develop plans of care to include the assessed needs for independent living skills and how people want and need to be supported. This will enable people to develop the skills needed for independent living and written plans will enable any progress to be reviewed. Where activity sheets have been assessed to be beneficial to people who use the service, these need to reflect actual activities. The medication procedures need to be reviewed to ensure there is a clear audit for medicines given to people and returned to demonstrate that people have received medication in line with dispensing instructions. Hand written Medication Administration Records need to be recorded and signed by two people to ensure the accuracy of dispensing instructions so people receive the correct medication. Information recorded in all documents needs to be accurate and reflect what has happened. Information passed to other parties as part of safeguarding procedures needs to be factual and reflect actual events to ensure safeguarding procedures can be followed and people are not placed at risk. 4 YA6 5 6 YA14 YA20 7 YA20 8 YA42 The Mount DS0000028634.V378389.R01.S.doc Version 5.3 Page 30 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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