Inspection on 16/05/05 for The Mount

This inspection was carried out on 16th 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 Mount 29/06/06

The Mount 26/09/05

The Mount 18/11/04

The Mount 14/07/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE THE MOUNT School Hill Wargrave Berks RG10 8DY Lead Inspector Susan Cledwyn-Davies Unannounced 16 May 2005, 9.30 am 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 H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Mount Address School Hill, Wargrave, Berks, RG10 8DY 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) 0118 940 2046 Majestic Number One Ltd Sarah Ntshudu Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom nursing care is provided at any one time shall not exceed twenty-nine. 2. Chronically disabled persons under the age of 60 will not be received except for respite care for periods not exceeding 3 weeks and 1 specified person. Date of last inspection 18 November 2004 Brief Description of the Service: “The Mount is a converted and extended Victorian house located on the northern bank of the river in the picturesque village of Warfield.The Mount accomodates up to 29 people needing nursing care and people needing residential care up to a total of 37 residents. The home is run by Majestic Number One ltd. Residents rooms are varied in size, many have en-suite facilities. There has been a lot of redecoration and new furniture provided. The communal areas being redecorated with new curtains and some new furniture. Specialised equipment has been obtained for resident comfort and safety. Residents are encouraged to bring in personal possessions and occasional furnishings to feel even more at home. Each room has a nurse call system and most have a TV. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9.30am and 2.50pm and was completed by 2 inspectors. The second inspector, Stewart Mynott, was newly starting with the CSCI and gaining extra inspection experience. The visit included a tour of the home, discussion with over 10 residents and 5 staff plus discussion with the senior on duty. There was examination of the records and observation of the lunch. In discussion with the Manager subsequently the term residents is used for the people who live in the home. Therefore this term is used in the report. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 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 H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 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, 3, 4 and 5. Standard 6 is not applicable. Both written and verbal information is given to prospective residents and relatives. All residents have their needs assessed prior to moving into the home. Visits to the home prior to admission take place, mainly by relatives. Resident’s needs are met in the home. EVIDENCE: The statement of purpose is up to date and available; the service users guide Is given to each resident and this was seen in residents rooms. Care plans showed that residents are assessed and an initial care plan prepared prior to admission. Both relatives and residents confirmed that visits to the home take place prior to admission and that a trial period is respected. At the end of the trial period residents are asked if they are happy in the home and wish to remain. The care plans demonstrated that residents’ needs are assessed and met. This was confirmed by observation and discussion with residents and staff. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 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 and 10 Care plans showed individual health, personal and social care needs; health care needs of residents are met. Medication practice is safe and conforms to the policy and procedure. Residents are treated with respect. EVIDENCE: Care plans demonstrate that care needs are assessed and changes take place. Records showed that care given improved some individual’s health and reduced care needs. Recently one resident has moved on to a home to live with more able residents. Care plans also showed improvement in current residents. The care plans were well maintained. It was noted that monthly reviews of care plans had not taken place in April. According to the Home’s procedure regularly reviews take place monthly. Staff are reminded of the importance of up to date assessment. The regular Doctors visit took place during the inspection. Residents were seen in their rooms. Care plans showed health referrals as necessary. There is a good working relationship with the local surgery. The medication storage and practice is good. Administration records were up to date. The medication procedure was in place. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 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) 13, 14 and 15 Residents maintain contact with family and friends. They have choice and control over their lives. Residents have a wholesome and varied diet. EVIDENCE: The activities officer had just left. A replacement has been advertised for. An activities calendar was advertised. There is a strong Friends of the Home association with regular meetings. Relatives were visiting during the inspection and spoke well of the home. There was a relaxed atmosphere and visitors were made welcome. Visitors were offered light refreshments. Residents were observed to have choice in their daily life. Residents themselves confirmed this e.g. in where to spend the day and in where meals are eaten. Meals are freshly prepared. There is a choice of hot meals at midday. The choice list was seen, all residents were not noted on this list. One resident not noted had spoken of not receiving the choice. It was agreed that the list would be updated more regularly. Lunchtime was observed. There are 2 dining rooms used plus residents can eat in their own rooms. It was noted that meals in the supported dining room were served on trays with a cup of tea. It was THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 10 noted that this was not normal practice and that meals would be on the table and tea later. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 11 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 and 18 Residents and relatives complaints are listened to and acted upon. Residents are protected from abuse. EVIDENCE: There is a comprehensive complaints system that is given to all residents and relatives. Complaints are treated proactively and the manager aims to resolve these amicably. Staff training in protection of vulnerable adults from abuse is taking place this year. There is a positive environment for staff and residents. Good care is encouraged. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 12 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, 20 and 26 The home is well presented and comfortable. Communal facilities have been improved. The home was fresh smelling and clean. EVIDENCE: The house is well presented, calm and peaceful. The communal areas have gradually been improved; the lounge has now had new curtains and furniture. Most of the bedrooms have now been decorated and some new furniture has been obtained. The garden is tidy; the grass is mown. Garden furniture and an umbrella have been put outside. The house was generally clean and fresh smelling. One bedroom was discussed with the staff because of unpleasant smell. The carpet had been cleaned and was cleaned again during the visit. Staff were asked to check that this room was improved. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 13 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 There was a satisfactory staff and skill mix of staff. EVIDENCE: Since the last inspection the home has achieved Investors in People status. On duty for 27 nursing and care residents were the Senior RGN plus a second RGN and five carers. Two of the carers are senior carers. It was confirmed by residents, relatives and staff plus observation that this provided satisfactory cover. The staff team worked well together. Staff were positive about the home, that care was well organised and the staff worked well together. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 14 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) 38 The health and safety of residents safeguarded. EVIDENCE: The health and safety was partially inspected. Accident records are monitored monthly and the number of accidents is reasonable. The kitchen was organised. Records of fridge and freezer temperatures and temperatures of cooked food were kept. The store cupboard shelving has been replaced, providing much better and safer storage. The kitchen floor remains in poor condition. This flooring is planned for replacement but has not been completed. The work has gone out to tender and it is planned to complete the work soon. This area is made a requirement to ensure prompt completion. The lift has been breaking down a few times recently. The engineer has repaired the lift but it would be helpful to consider if this should be replaced in the next couple of years. A new aerial has been put in place to improve the call bell system. While work has been completed redecorating and providing THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 15 new furniture there are also some larger service repairs that are now being considered over the longer term. The regulation 26 visits by the representative of the proprietor took place regularly. Records were kept in the home. THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 16 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 2 THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 17 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. 2. Standard 15 38 Regulation 16 23 Requirement That all residents are given the choice of meals and that a record be kept of this. That the kitchen floor be replaced. Timescale for action 1.6.05 1.8.05 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. Refer to Standard Good Practice Recommendations THE MOUNT H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Business Park Theale Berks RG7 4SA 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 H52-H01-S11007-The Mount-V217762-160505Stage 4.doc Version 1.30 Page 19 - 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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