Inspection on 17/04/08 for The Mount

This inspection was carried out on 17th April 2008.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mount 30/04/09

The Mount 18/04/07

The Mount 19/12/05

The Mount 07/09/05

The Mount 03/11/04

The Mount 21/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 The Mount 6 Liverpool Road, North Burscough Nr Ormskirk Lancashire L40 5TP Lead Inspector Phil McConnell. Key Unannounced Inspection 17th April 2008 10:00 The Mount DS0000040694.V358822.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 DS0000040694.V358822.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 Older People and 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 DS0000040694.V358822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Address 6 Liverpool Road, North Burscough Nr Ormskirk Lancashire L40 5TP 01704 893907 01704 896181 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) Social Services Directorate Miss Karen Smith Care Home 4 Category(ies) of Learning disability (4) registration, with number of places The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 4 service users to include; Up to 4 service users in the category of LD - Learning Disability. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 18th April 2007 Date of last inspection Brief Description of the Service: The Mount is owned and run by Lancashire County Council and provides respite and short term care for a maximum of four people over 18 years of age with learning disabilities. The Mount is on a busy main road and is in walking distance of local amenities and public transport. The home is a dormer bungalow with 4 single bedrooms. There is a lounge/dining room and conservatory area communal space. There are facilities such as a ramp, disabled toilet and other aids to help service users remain as independent as possible. A large, well-maintained and secure garden to the rear of The Mount gives additional space when the weather is good. The Local Authority usually funds service users. There was information available to potential service users and their families advising them of the service and giving them details about the type of service they could expect. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adeqaute quality outcomes. Various information was gathered in order to assess the key standards that are identified in the National Minimum Standards for Care Homes for Younger Adults, including: the pre inspection questionnaire, (completed by the registered manager) and an unannounced inspection visit to the service on the 10th of April 2008, with a follow up visit on the 17th of April 2008 to give some feedback to the registered manager. Four service users’ files were examined and all relevant documentation was in place. The staff files contained most of the information that is needed for inspection purposes, however some of the staff recruitment information is stored at the main office in Preston. It was suggested that a checklist be kept at the home, demonstrating the recruitment process. (See staffing section) There was the opportunity to observe the support and care being provided to the service users on both visits to the Mount. The home’s policies, procedures and all other documentation including health and safety files and certificates were examined. (See management section). A full tour of the home was also carried out. (See environment section). What the service does well: What has improved since the last inspection? The newly introduced quality monitoring systems show that there is a commitment to providing a good service. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 6 The complaints procedure has improved, with clear information readily available. The risk assessment process has improved, giving the assurance that people are enabled and empowered to take manageable risks, which potentially promote their independence. Staff supervisions have become more frequent, enabling to monitor staff performance and giving staff the assurance that they are valued. 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 DS0000040694.V358822.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. Individuals’ needs are appropriately and satisfactorily assessed, helping to give the assurance that people are very well supported and cared for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six service users’ files were examined, including the last person to receive a short break/respite service at The Mount. Pre admission care assessments (SS1B’S) were in place and they contained relevant, appropriate and good information to determine a person’s individual needs. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 9 The staff spoken to during the inspection visit had a good understanding of the assessment procedure for new prospective service users, saying that it includes, a home visit, a visit to the Mount and usually a tea visit prior to a short break provision being provided. This enables the person and the staff to become more familiar with each other, in order to make their stay as enjoyable as possible. It was evident that a new system has been introduced since the previous inspection from the commission for social care inspection (CSCI), with a ‘New Arrivals’ checklist folder, containing relevant forms, in order to obtain as much information as possible. There is also a ‘Departure file’, containing any finance receipts, list of clothes returned and a quality monitoring questionnaire for the service user and their relatives. This all helps to demonstrate that the provider is committed to ensuring that the pre admission assessment and initial introduction to The Mount is based on meeting peoples’ individual needs. The AQAA states, “We have a clear assessment and admission procedure, which ensures the care needs of people are met” This is clearly demonstrated by the new satisfactory systems that are now in place. It was evident that the care planning system has also improved since the last inspection visit, helping to demonstrate that peoples assessed needs are regularly monitored and if peoples’ needs change then care plans are appropriately adjusted, in order to ensure that peoples’ needs will continue to be provided. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. People are supported and empowered to make informed decisions and take assessed risks, which promote and enhance their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was apparent that peoples’ care plans are mainly completed with the information that is gathered by the assessment process. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 11 As already mentioned there was evidence that peoples’ care plans are up to date, more detailed and are being reviewed on a regular basis. This was a previous requirement. Service users’ ‘key workers’ have the responsibility of ensuring that peoples’ files are up to date and in order, they attend day centre reviews and person centred planning meetings (PCP’S) in order to ensure that they are familiar with peoples’ ongoing needs, wishes and aspirations. Having a designated key worker helps give the assurance that peoples’ changing needs will be quickly identified and therefore acted upon. The AQAA states, “ We liaise regularly with social workers, teams and in house services to ensure a consistent approach” and “When consulting with people we support, parents and carers we listen to both parties, to achieve the best possible outcomes, ensuring the person using the service has a voice”. It was evident that service users are included, involved and encouraged to make choices and take decisions that affect their daily lives. It was also clear that people’s relatives or representatives are actively included. In talking to some of the service users, it was clear that people are encouraged to make their own decisions and choices. The service users observed during the inspection visit appeared to be relaxed, content and trusting of the staff present at the time. One relative wrote, “Everyone takes great care to keep my daughter happy and have become familiar with her likes and dislikes and provide quality loving care”. There were corporate and individual risk assessments in place, helping to show that people are encouraged and empowered to be as independent as possible. In observation it was clear that service users are treated with respect, and dignity in an inclusive and empowering way. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 13 12, 13, 15, 16 and 17. Quality in this outcome area is good. People are positively supported in participating in meaningful and appropriate activities, in order to provide stimulation, motivation and promote community presence and inclusion. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Peoples’ care plans are concise and detailed giving, clear guidance and information about the various interests and activities that individuals are involved in. The AQAA states, “We consult with people prior to their stay, to ask of any particular activity they would like to do whilst at the Mount. This ensures staffing levels are correct and does reflect their needs”. One of the staff commented, “Booking forms are sent out to service users/relatives six months in advance and then together as a team we decide which service users ‘best match up’ in order to allow for what activities individuals have requested. For example younger people may be more active and want to go dancing, whereas older folk may like to go for meals out and shopping”. In speaking to members of staff and from feedback received, this planning and consideration of compatibility has generally been very successful. It was also evident that people were individually involved in different activities and pursuits in the local community. There was also evidence that people are supported and encouraged to access meaningful leisure pursuits away from the immediate area, with the Mount having regular access to a mini-bus, which has a rear tail lift, enabling people who use wheelchairs to fully participate in this activity. It was evident that inclusion, community participation and community presence is positively and actively promoted, enabling people to maximise their independence, whilst also initiating self worth, confidence and wellbeing. Records of all meals are maintained and it was evident that consideration is given to promoting nutritious and well balanced diets. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. Peoples’ health care needs are satisfactorily provided, with people being enabled and empowered to communicate their choices and wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some of the people who stay at the Mount for short breaks do require some support with their personal care needs and this is carried out with their full agreement. The AQAA states, “We liaise with community learning disability nurses for guidance and support for the individuals needs, so that we can develop protocols to ensure we are effectively meeting the needs of the individual” The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 15 If there is a need for someone to see a GP or attend an appointment during their stay, support is provided and the outcome is recorded and the information is passed on to the service users relative. Service users have up to date health needs checklists, health action plans and as already mentioned detailed care plans. Intimate and personal care requirements and specific health needs are identified and recorded with key workers being responsible for monitoring and reviewing. It was evident that aids and adaptations are provided to assist people with their individual care needs. There was an appropriate medication policy in the home and the medicines were securely and correctly stored and administered, with medication charts being accurately recorded and up to date, with two signatures for each administration. Service users’ files also contained signed ‘medication declarations’. This document gave permission from either the service user or their representative for the care staff to administer medication. (This was a previous requirement). All staff have received satisfactory training in the medication process. Since the last inspection visit the medication procedure has been reviewed and medication procedures are now a regular item in supervision sessions. This is to help ensure that the correct medication procedures are being maintained. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. The limited safeguarding adults training is potentially putting people at risk from harm or abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was a satisfactory complaints policy and procedure in place. The AQAA states, “We have good arrangements in place for handling complaints and ensure people who use the service feel confident that their complaints and concerns will be listened to”. New service users or their representative are given a copy of the complaints procedure and discussion takes place, to ensure that there is a full understanding of the procedure. No complaints had been received since the previous inspection. New ‘quality monitoring’ forms have been introduced, which included sections for complaints, concerns and compliments. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 17 The feedback received from relatives demonstrated that people are aware of how to make a complaint if they need to. There was some evidence that safeguarding adults issues have been discussed at staff meetings, however it was clear that staff have not received any ‘formal’ safeguarding adults training. In discussion with some of the staff, it was apparent that people would know what to do in the event of any suspicion or allegation of abuse and they were aware of the ‘No Secrets’ document, which is a government guidance publication on the protection of vulnerable adults. The need for up to date safeguarding adults training was discussed with the manager and an assurance was given that this issue would be appropriately addressed. This would help ensure that people are satisfactorily equipped and skilled to correctly deal with any issues relating to safeguarding adults. The home contains relevant evidence that all members of staff have had criminal record bureau clearance checks carried out (CRB), helping to show that the organisation is committed to protecting the people in their care. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. The poor lighting and tired décor needs to be addressed, in order to improve the overall environmental standard of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home was carried out and it was observed that a new wet room was in the process of being completed, “Which will be benefited by all people The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 19 who use the service”. The four bedrooms were all clean and tidy, with the necessary hoists and equipment available for individuals who need extra support. The kitchen has recently been refurbished to a good standard and it was found to be clean and hygienic. One person wrote, “It’s home from home, providing a warm welcoming atmosphere”. The laundry is sufficiently equipped to cater for peoples needs. It was suggested that the laundry be kept locked when not in use, this would help ensure that individuals are protected from potential accidents. Generally the home was clean, hygienic and comfortable, however some of the décor is looking very tired, old fashioned and too dark, especially in the lounge area. The lighting throughout the home is quite poor and it was suggested to the manager that the ‘energy saving’ light bulbs be replaced with standard light bulbs. The ceiling fitting in the lounge is too low; consideration should be given to replacing this with a more appropriate / suitable fitting. The water temperatures in the bathroom and in the kitchen are much too hot. An assurance was given by the manager that this will be immediately addressed, to ensure that people are safe and protected. There is good access to the well-maintained rear garden and it was commented that this area is used more in the summer months. The front of the building has a neat garden with good parking space, however it is apparent that the window frames at the front of the property are in need of some restoration or being replaced. The poor maintenance could give a false impression to the outside community that people are not being properly supported. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is adequate. Although the staff team are well established, committed and caring. There is a need to ensure that people are satisfactorily trained, in order to give the assurance that vulnerable people receive the best possible support and care available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 21 Four staff files were examined and they contained some relevant information including, criminal record bureau checks (CRB), supervision and some training records, however as already mentioned the provision of formal safeguarding adults training is not being provided. The national vocational qualification (NVQ) also falls short of the necessary number of staff to have achieved this care award, with only 30 of staff having completed it. The staff recruitment documentation including, application forms and references are kept at the head office. It was suggested to the manager that it would be good practice to keep a record in the home of all the required recruitment documentation, which is listed in the national minimum care standards. (Previous requirement). Supervisions were previously infrequent, however there was evidence that they are occurring more frequently. There was also evidence that regular staff team meetings are now taking place, this is also an improvement since the last inspection. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. The home is well managed, with quality monitoring procedures in place. This judgement has been made using available evidence including a visit to this service. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 23 EVIDENCE: The homes manager has been in post for only six months, but it is apparent that some positive changes have taken place. There was evidence to show that plans are in place to bring about further improvements, which will benefit service users and the people working at the Mount. The manager has applied to be the registered manager with the commission for social care inspection (CSCI). In discussion with the staff, it was clear that the changes that have been made are very much appreciated. It was also apparent that the manager is seen to be approachable, supportive and well organised. Some of the changes that have been implemented include the quality monitoring forms, the telephone surveys made to relatives and the improved frequency of staff supervisions. This shows that the quality monitoring of the service being delivered is important to the provider. The health and safety policy and procedures were examined and found to be up to date. All of the required inspection safety certificates were in place and up to date, including, electric, gas, hoists, and fire alarm. The records for monthly fire drills were observed. These all demonstrate that the provider is committed to providing a safe and secure environment for people to live and work in. The manager was advised to ensure that regulation 26 monthly reports are sent to the CSCI, in order to show that ongoing improvements are being maintained. The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 24 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. 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 Standard No Score 1 X 2 3 3 X 4 X 5 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 1 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 2 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Mount Score 3 3 3 X DS0000040694.V358822.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 13 (4) (a) Requirement Timescale for action 30/06/08 2 YA24 23 (2) (b) & (d) Schedule (2) 19 3. YA34 All parts of the home to which service users have access are free from hazards to their safety. (Water temperatures) The care home should be kept in 31/08/08 a good state of repair externally / internally and reasonably well decorated. Documentary evidence 30/06/08 (recruitment) as described in Schedule 2 of the Care Home Regulations must be kept at the home and be available to the inspector. (Previous timescale 28/9/07) The registered person shall ensure that persons employed at the care home shall receive training appropriate to the work they are to perform.(Safeguarding adults). (Previous timescale 30/11/07) 31/08/08 4. YA35 18 (1)(c) The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA23 Good Practice Recommendations A photograph should be kept of each service user. The registered person should ensure that by staff training or other measures, to prevent residents from harm, abuse or being placed at risk or harm or abuse. The registered person should ensure that persons employed at the care home shall receive training appropriate to the work they are to perform. Risks to service users health and safety are identified and so far as possible eliminated. 3 YA32 4. YA42 The Mount DS0000040694.V358822.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 DS0000040694.V358822.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. 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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