Inspection on 17/04/07 for The Mount

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 10/11/09

The Mount 05/12/08

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 09/07/2008.

CARE HOME ADULTS 18-65 The Mount Wood Lane Yoxall Staffordshire DE13 8PH Lead Inspector Kathryn Marks Key Unannounced Inspection 17 April 2007 09:00 The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 DS0000028634.V335353.R01.S.doc Version 5.2 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 Vacant post Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (1) of places The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 6 LD aged 18 - 30 years on admission. Admission of one named individual under 18 years on admission Admission of one named individual over 30 years on admission One service user with diagnosed Mental Disorder with some learning Disabilities. 5th July 2006 Date of last inspection Brief Description of the Service: The Mount currently provides care for five adults with a mild learning disability and challenging behaviour. The home can cater for individuals ranging from 18 to 65 as per assessed need and suitability of placement. The property is a large detached modern house set in extensive grounds in a rural setting close to the small village of Yoxall, near to the town of Burton-onTrent and the city of Lichfield. Service users are admitted on the basis of education and rehabilitation planned towards either independent or semi-independent living. The home provides relevant staffing levels to meet individual needs. Residents are encouraged to fully participate in the daily running of the home, hold their own food budget, to assist in the preparation of meals and housekeeping tasks. The service users are encouraged to choose their own college courses and are supported by staff to access the college. The property is situated close to the local Post Office and shop and is on a main bus route for Burton-On-Trent and Lichfield. The proprietor provides mini bus transport. All residents have their own personal bedrooms and a wide range of leisure activities on site, swimming, snooker, music and gardening. The home has access to specialist health services such as Psychiatrist, Psychologist and specialist nurses for learning disabilities subject to an appropriate referrals procedure. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 5 The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection carried out on 17/04/07 and covered all of the core standards. The inspection took place over 7 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. A tour of the home took place with staff and the five younger people living here. Prior to the inspection visit, survey information has been requested from individuals and their relatives. The inspection included an examination of records, indirect observation, and discussion with the five young people living here although understanding and conversation at times is limited. The Acting Care Manager was available throughout the inspection other staff were spoken with whilst working with individuals. Case tracking of two care plans took place. Three staff records were examined and observations were made of interaction with young people during daily events. What the service does well: As at the previous inspection The Mount continues to offer a good standard of care and was observed to be well organised with a committed acting care manager and staff team. Young people and their families are encouraged to be involved in the process of care to ensure a personal approach to meeting individual needs. The young people spoken to say they were happy at the home and were observed to enjoy their daily routine/activities today. Assessment procedures and care planning is of a good standard offering detailed information on individuals development. Staff and young people were observed to work together as a team. Observations were of a well-trained staff group who receive regular supervision records of which were seen on staff files. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 7 Health care needs are well met with regular discussions and health care audits being carried out. Referrals are made as appropriate to health care services. 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 summary of this inspection report can be made available in other formats on request. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 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.V335353.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a variety of information regarding the home and the services it provides available to individuals. Young people are given the opportunity to visit the home and stay overnight prior to moving in. EVIDENCE: The Home has in place a Statement of Purpose and Service users Guide providing individuals and carers/relatives with details of the services the home is able to provide enabling an informed decision about admission to be made. These documents were seen and are being updated to include the no smoking in the house policy. Observations were made on care records of assessments being carried out prior to admission to the home. Parents, carers, social worker, are all involved in the assessment process. Young people are asked on pre-admission visit about how they felt about the home and a resident spoken with said he made a visit and talked to staff. Observations were made of contracts being in place when looking at individual’s files. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 10 There have been no new referrals since the last inspection. There is one vacancy at the home and when this is filled The Acting Care Manager is reminded that to ensure compliance with Regulation 14 of the Care Homes Regulations she should confirm in writing to the young person and their carers the homes suitability to meet the needs of the prospective individual. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Where necessary individuals are supported/assisted to make decisions about their daily lives and routines. Care plans and risk assessments are detailed and covers most areas of resident’s lives. EVIDENCE: A sample of three care plans were inspected and found to offer good records of daily routines. Each plan included an assessment and details of individual needs and the support required, personal information, a person centred plan, visual planners, risk assessments and how individuals were supported. Planned interventions, rehabilitation and therapeutic programmes where appropriate, are also in place. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 12 Individuals were making decisions about their daily routines and observations were made of them being encouraged to do so. Two young people went into Lichfield and another went out with a member of staff for a ride. On their return one individual spoken to say they had enjoyed the day out. Individuals with assistance were able to make decisions and decide on weekly planner areas including shopping, what they are to eat, activities, and finances. Staff during conversation confirmed this. Inspector had lunch with young person and staff member and observed choices of food being made. All can verbally make their needs known and identify what they want however at times may not be able to express their feelings. Procedures are in place for individuals who display challenging behaviour and are identified on care records. Individual risk assessments were in place on care records for young people providing information relating to potential hazards and details of measures to reduce or eliminate risks. Very dependent group of individuals where total independence is limited all have one to one staff time allocated. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in a variety of daytime activities according to choice, personal interests and capability. EVIDENCE: On the day of inspection five young people were resident at the home. Two individuals went out for the day two remained at home and a third Went out for a ride with a staff member. Discussions with service users and staff identified that there is a range of day opportunities available for individuals to be involved in as they choose. Each individual has a personal plan for the week in place. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 14 Educational opportunities include Cannock and Rodbaston Colleges Burton, Lichfield and Stafford College; all offer a variety of opportunities for individuals. Work Placements are available at a number of locations including IMEX centre Burton, Black Country Museum, Countryside services, Wildlife Trust, Staffordshire County Council Rangers. Social Activities a whole list is available in the home and individuals preferred choices are identified. During the course of this inspection staff were observed to be treating individuals with respect and communicating in a way the individual could understand. Individuals are involved in the menu and make choices about food verbally or via pictorial form. Mealtimes are flexible to meet the needs of individuals. Dietary needs of individuals are well catered for with a balanced and varied diet being provided. Known personal likes and dislikes are taken into account. One young person is assisted to purchase and prepare own food and said he enjoyed doing this. A lot of staff support is given to achieve this. Generally there are structured plans in place for daily routines but they are flexible dependent on how a particular person is on the day. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff had a good understanding of individual’s needs and preferences. The delivery of personal care is flexible and person centred staff respecting the privacy and dignity of the young person. EVIDENCE: Individual care plans recorded the level of support required and the one to one hours allocated to all young people at various times of the day to support identified needs. Observation was made of a staff supporting one individual. Staff explaining the support required by the young person and inspector observing the time being given. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 16 A high standard of care is delivered at The Mount by experienced caring staff and individuals responded to this. Physical and health care needs were being met positive responses were seen taking place between staff and individuals. As at previous visit the general atmosphere throughout the home was one of a relaxed, sensitive and warm home. Good relationships had been built up with staff that treated individuals respectfully. All individuals are registered with a local General Practitioner with healthcare needs being met by appropriate referrals where necessary. The Acting Manager is enquiring about Well-Man and Well-Woman clinics in the area that are available to individuals. At the time of this visit following risk assessments there are no individuals selfmedicating. Policies and procedures are in place for the management of medication. Medication Administration Sheets were reviewed and found to be signed appropriately and up to date. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Mount has in place a complaints procedure that is easy to understand. Records are maintained of individual’s monies. EVIDENCE: The home has in place a clear complaints procedure that an individual identified during conversation with them. Staffs were observed encouraging individuals to discuss any areas of concern with someone they felt comfortable with. Where appropriate individuals are assisted to make a complaint or raise a concern. Records are kept of all concerns and complaints. Grumbles book was seen. The Acting Care Manager ensures that individuals are protected from abuse by staff training, observations of staff and relatives. Staffs have access to appropriate Protection of Vulnerable Adults procedures. Vulnerable Adults training has been carried out at The Mount and Abuse training is arranged for 15/05/07. Staffs have received training in physical intervention techniques with an emphasis on diversion and distraction. Resident’s finances are securely stored. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 18 The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,28,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As at previous inspection the facilities in the home are domestic in style and provide individuals with a comfortable homely environment. Attention is given to ensure a safe and secure residence. EVIDENCE: Observations when walking around the home were of a clean well-maintained environment. Individual bedrooms were visited with the person occupying the bedroom. Individuals all had individual planners on bedroom walls identifying what they were going to be doing and were able to explain plan to inspector. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 20 There are communal facilities shared by all lounge, dining/kitchen, and games room, swimming pool that is locked and used only with trained lifeguard. The home is suitable for its stated purpose safe, bright, and is being updated through a planned programme. The Management are ordering New mobile call bells to enable individuals to move them around with them ensuring assistance can be summoned when required. Local community facilities are easily accessible and frequently used by individuals who can walk into the village. Generally the home presents as clean, comfortable and odour free. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35,36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The young people living at The Mount are protected by safe staff recruitment procedures and supported by ongoing staff training and supervision. The staffing provided is based around delivering outcomes for the people using the service. EVIDENCE: There are five young people resident at the home receiving care at the time of this inspection. There is a group of longstanding staff that has a good understanding of individuals and their needs. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 22 Off duty provided with the pre-inspection questionnaire evidenced that the home is appropriately staffed to meet the diverse needs of individuals. There is three staff in the morning and evening shifts, one night staff with a sleeping in carer on duty. Staffs on duty were as per rota. The Acting Care Manager was also present in the home. Observations of the inspector where that staff were knowledgeable about the needs of residents in their care and were meeting those needs in a sensitive caring way. Robust recruitment policies and procedures are in place, Criminal Records Bureau checks, Pova checks, and two references are taken up prior to the appointment of staff. All new staff is subject to a probationary period. Three staff files were examined. Observations were made of Criminal Records Bureau and POVA checks being on file. Records of previous employment and references were also seen. Staffs training records were in place but would benefit from being centralised in the form of a matrix for easy identification of what is due when. All staff receives training specific to their post. Regular supervision takes place this is booked on a two monthly basis but does not always happen if individuals need staff time. Records were seen on staff files examined. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42,43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an experienced acting care manager in place at the home whilst they are recruiting for a permanent Care Manager. All staff demonstrated an awareness of their roles and responsibilities. EVIDENCE: The Acting Manager who has NVQ level 4 and the Registered Managers Award ensures so far as is reasonably practicable the health, safety and welfare of service users. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 24 Staff had received training in; Moving and Handling, Fire Safety, First Aid, Food Hygiene, and Infection Control a training matrix would identify ongoing training needs more easily. Hazardous substances are securely stored and regular servicing of equipment and systems is carried out. The Acting Manager ensures compliance with relevant legislation and risk assessments are in place for safe working practices. Security of the premises is provided on the main entrance door via a digital lock also on the gate at the end of drive. The inspector observed the home to be well run with clear lines of accountability to the Acting Care Manager however a permanent registered care manager must be appointed. This is a requirement of this report. The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 2 3 X X 3 2 The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 26 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 YA43 Regulation YA8 Requirement The registered provider shall appoint an individual to manage the care home where there is no registered manager in respect of the care home. Timescale for action 01/08/07 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 YA19 Good Practice Recommendations Attend well man and well woman clinic The Mount DS0000028634.V335353.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000028634.V335353.R01.S.doc Version 5.2 Page 28 - 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. 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