Inspection on 14/04/05 for The Mount

This inspection was carried out on 14th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Mount 23/06/09

The Mount 30/06/08

The Mount 06/08/07

The Mount 27/11/06

The Mount 07/06/06

The Mount 24/10/05

The Mount 05/10/04

The Mount 15/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Mount 226 Brettell Lane Amblecote Stourbridge DY8 4BQ Lead Inspector Mike Kirton Unannounced 14th & 18th April 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 Mount Version 1.10 Page 3 SERVICE INFORMATION Name of service The Mount Address 226 Brettell Lane, Amblecote, Stourbridge, Dy8 4BQ 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) 01384 265955 01384 265955 Mrs Jenny Green Miss Marcia Sandra Reid CRH 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Mount Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 service user under the age of 65. Condition to be terminated once they leave or reach the age of 65. Date of last inspection 5th October 2004 Brief Description of the Service: The Mount is a residential home registered to provide 24-hour care and support for 18 people over the age of 65. This includes a recent extension to incorporate a previously detached bungalow. The property is a large two storey detached house, situated on the main Amblecote to Dudley Road and is close to public transport and local amenities. There are gardens to the front and rear and car parking facilities to the side of the house. All rooms are for single occupancy the majority of which have en-suit toilet facilities. There is a small lounge area with attached conservatory within the dining area, a larger main lounge and a further small lounge in the bungalow extension. Access to the first floor is via a lift or main stairway. The laundry is located in the cellar and is not accessible to service users however this will be moved shortly to a new location. There is one assisted bath located on the 1st floor a shower room and new walk-in shower on the ground floor. The Mount Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection the Inspector spoke with eight residents, three visiting relatives, five staff members, the manager and owner. The Inspector also walked around the home and inspected the kitchen, bathroom, and laundry facilities. Although unable to look at individual care plans the Inspector examined the medication records, storage facilities and staff files. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Mount Version 1.10 Page 6 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 Mount Version 1.10 Page 7 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) 1, 2, 3 & 4 Although excellent feedback was received from residents the homes standard of recording and structure of files made it impossible for these standards to be fully assessed. EVIDENCE: Admission procedures are not being followed in that the required contracts or assessments are not completed and / or recorded. Neither has the homes statement of purpose and service user guide been updated. Feedback from relatives and their relatives however praised the staff on how they had quickly helped them settle into the home and that they should be given a ‘gold star’ for all the help they have given. Intermediate care (rehabilitation) is not provided. The Mount Version 1.10 Page 8 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, 8 & 9 The homes consistent poor recording and filing makes the task of assessing how they are meeting residents needs very difficult. In areas of administration of medication and monitoring health care needs this is a potentially dangerous practice. EVIDENCE: Service users care plans are not being completed or reviewed on a monthly basis (or when required) and risk assessment are not being undertaken to prevent the risk of falls or developing pressure sores. Serious concerns were identified regarding the administration of medication and immediate action was taken to rectify this. Record sheets were not being followed and often completed incorrectly. Service users and relatives reported that staff always treated them well, were very kind and all their needs were being met. One comment received described the home as ‘superior to all others’. The Mount Version 1.10 Page 9 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) These standards were not assessed on this occasion. EVIDENCE: The Mount Version 1.10 Page 10 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) These standards were not assessed on this occasion. EVIDENCE: The Mount Version 1.10 Page 11 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, 21, 25 & 26 Improvements have been made to the premises since the last inspection however work is still required on several areas in the home particular the older buildings. Overall the environment is comfortable, has a homely atmosphere and is clean and tidy. EVIDENCE: The main dining room and lounge areas are all nicely decorated and well maintained. Outstanding work is required on the security of the office door, relocation of the washing machine to the new laundry room and the covering of radiators. The plan of routine maintenance also requires completion and the replacement of bedroom furniture as required. Care must be taken to prevent damage to the new fire doors by the use of wedges; these are also a fire hazard and must be removed. All fire doors must close correctly into the frame. The Mount Version 1.10 Page 12 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, 28, 29 &30 Improvements have been made regarding staff training however there are serious concerns regarding the homes recruitment procedures. Whilst all staff met demonstrated they were more than competent in their jobs stricter policies and procedures must be applied. EVIDENCE: The home’s staffing rota did not accurately reflect the numbers working at the home or the roles they were undertaking. Recruitment and employment procedures were not being followed before appointment including checking for previous criminal offences. All new staff are now required to attend a 5 day induction programme at college however there was no accurate record of staff training or foundation courses. The structure of staff files and the way in which information was recorded made it difficult for me to fully examine these standards. Staff met during the inspection said they enjoy working there and felt supported be colleagues and the manager. They were concerned however about the staff and manager who will shortly be leaving and how this will effect the home. The Mount Version 1.10 Page 13 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) 31, 36, 37 & 38 It is evident that there are serious shortfalls in the way the home is managed. It appears however that this has not impacted on the positive outcomes for service users who all enjoy living at the home. EVIDENCE: The registered manager will shortly be leaving The Mount. Staff, service users and relatives all spoke highly of her and are concerned about the future of the home with this position vacant. Action must be taken to improve on the poor recording and filing systems, lack of policies and procedures and failure to meet outstanding requirements. This has affected the level of supervision and training available for staff and poor health and hygiene standards in the kitchen area. The home will be closely monitored to ensure appropriate steps are taken. The Mount Version 1.10 Page 14 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. Where there is no score against a standard it has not been looked at during this inspection. 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 1 1 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x 2 x x x 2 2 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 1 x x x x 1 1 1 The Mount Version 1.10 Page 15 Yes 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 1 Regulation 4, 5 & 6 Requirement Copies of the statement of purpose and service users guide must be available to perspective service users and their relatives and must contain all the required information. Ammendments must be forwarded to the CSCI within 28 days. This is an outstanding requirement. All service users must have the required contract completed, dated, and signed. All service users must have a full assessment of their needs completed before admission or within 5 working days for emergencies. Care plans must be developed for all service users and reviewed monthly or when needed. They must cover all aspects of health and social care and include risk assessments with particular attention to the prevention of falls. This is an outstanding requirement. Complete risk assessments for all service users to include moving and handling, nutritional Version 1.10 Timescale for action 01/07/05 2. 3. 2 3 4,5 & 6 14 01/06/05 14/04/05 4. 7 15 01/06/05 5. 8 12 & 13 01/06/05 The Mount Page 16 6. 9 13 7. 19 23 8. 24 23 screening and prevention of pressure sores. These must be reviewed. The home needs to ensure that all service users health needs are being assessed and monitored including specialist medical, nursing, dental, chiropody, hearing, sight tests and therapeutic services. These are outstanding requirements. Where service users are in 14/04/05 receipt of PRN (as and when necessary) instructions must be available for when this is to be administered. Medication not administered must not be signed as given or in advance. Medication received from the chemist must be checked against the prescriptions with any errors recorded and corrected. Medication no longer needed must be returned to the chemist. There must be no gaps in the medication records. Service users must have a photograph on their records. Staff responsible for administration must be appropriatley trained. These are outstanding requirements. The office door must be kept 01/05/05 locked when not in use. Staff must still have access to service users records and phone. Develop a programme of routine maintenance and renewal of the fabric and decoration of the individual rooms and exterior of the building. Door wedges must not be used. These are outstanding requirements. Bedrooms must contain all the 01/06/06 Version 1.10 Page 17 The Mount 9. 10. 26 27 23 18 &19 11. 29 18 & 19 12. 30 18 & 19 13. 33 21 & 24 furniture as required under this standard unless not required by the service users or the risk assessment finds that it would be unsafe to do so. This is an outstanding requirement. The washing machine must be moved to the new laundry room. The staffing rota must accurately reflect the number of staff, their names and duties they are covering. This includes the hours worked by the manager. A policy and procedure must be introduced by the home regarding the reqruitment of staff, use of students on placement and people under the age of 21 and 18. These are outstanding requirements. Staff must have a statement of terms and conditions/contract and start dates must be recorded. Ensure that all information contained in Schedule 2 of the Care Homes Regulations 2001 in relation to the fitness of staff employed is undertaken prior to commencement of employment. These are outstanding requirements. All staff must also have an individual plan showing current training/qualifications and when updates are required. All staff must undergo foundation training to the Training Organisation for Personal Social Services specification. These are outstanding requirements. Review the quality assurance and monitoring system. Seeks views from service users, staff Version 1.10 01/06/05 14/04/05 14/04/05 01/06/05 01/07/05 The Mount Page 18 14. 36 18 15. 37 17 16. 38 12 & 13 17. 38 12, 16 & 37 18. 38 12 & 13 and other stakeholders. This is an outstanding requirement. Staff must be provided with regular supervision (a minimum of six per year) that covers all aspects of practice, philosophy of care in the home and career development needs. This is an outstanding requirement. All the required information as listed under schedule 3 and 4 of The Care Home Regulation 2001 must be available.All records must be accurate, in good order and secure. This is an outstanding requirement. Review water temperatures to ensure that they are between 10C and 30C to reduce the risk of scalding and legionella. Provision of radiator covers or low surface temperature radiators throughout the home. Risk assessments need to be carried out on the building and on staff activities, service users and any visitors both inside and outside the home. This is an outstanding requirement. Regulation 37 notices must be sent to the Commission for all notifiable incidents. A procedure must be implemented to ensure all the required food health and saftey checks are completed daily including cleaning, stock rotation, & temperature checks. Implement policies and procedures as required, signed and dated by the manager. 01/05/05 01/05/05 01/06/05 14/04/05 01/06/05 The Mount Version 1.10 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Mount Version 1.10 Page 20 Commission for Social Care Inspection Muchlow Office Park West Point Mucklow Hill Halesowen B62 8DA 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 Mount Version 1.10 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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