Inspection on 23/04/08 for The Mount

This inspection was carried out on 23rd April 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mount 13/04/07

The Mount 08/12/05

The Mount 30/06/05

The Mount 05/10/04

The Mount 21/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 The Mount 29 Palmer Lane Barrow On Humber North Lincolnshire DN19 7BS Lead Inspector Ms Wilma Crawford Key Unannounced Inspection 23rd April 2008 09:30 The Mount DS0000002815.V362857.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 DS0000002815.V362857.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 DS0000002815.V362857.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Address 29 Palmer Lane Barrow On Humber North Lincolnshire DN19 7BS 01469 532897 F/P 01469 532897 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Ltd Miss Leanne Marie Sanders Care Home 19 Category(ies) of Learning disability (19) registration, with number of places The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Learning disability - Code LD The maximum number of service users who can be accommodated is: 19 13th April 2007 2. Date of last inspection Brief Description of the Service: The Mount in Barrow on Humber, owned by Prime Life Ltd, provides personal care for adults with a learning disability. Accommodation is provided for 13, people in single rooms (except for one double), on two storeys in the main house. Further accommodation is available in a one bedded and three bedded self contained bungalow. Each of the properties is set in their own grounds and although the main house is not suitable for people with physical disabilities, one of the bungalows is adapted for wheelchair use. On April 23rd 2008 the manager provided information that the home’s charges range from £319.00 to £936.87 per week, for which care and accommodation are provided. These fees are based on a standard fee and an additional package of hours based on the individuals needs. People living in the home are required to purchase their own clothing and toiletries, to pay for meals out if they choose to take them, and to pay for use of the home’s transport by making an agreed monthly contribution. Local shops and amenities are close by in the village and the home has its own transport. There are large gardens for residents use, which are used extensively in the summer months. The Mount DS0000002815.V362857.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 adequate quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 13th April 2007, including information gathered during a site visit to the home. The site visit was unannounced and took place over eight hours including preparation time. Five people living in the home, a relative and three staff were spoken with during the visit. Fifteen surveys were sent out to the staff team and five of these were returned, the comments from the surveys and from the discussions during the site visit are also included in the report. The manager was available throughout the visit. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices.The premises were looked at and the records of three residents and two staff were inspected. An Annual Quality Assurance Assessment (AQAA) document asking for information about the home was sent out before this visit and information from this was included as part of the inspection process of this service. What the service does well: People living in the home are assessed before they receive a service of care and support in the home, and they are provided with some information about the home and staff in order to decide whether or not their needs can be met there. Individuals have their needs and changing needs recorded in a plan of care, which takes into consideration their individual differences. They are encouraged to make their own decisions about daily life, as much as possible, which may involve taking risks in order to achieve independence. However, these risks are reduced where possible, through the risk assessment process. People living in the home said that they receive the help and support with personal care and with physical and emotional health needs in a way that suits them. They have their views listened to and feel confident they can make representations or concerns and complaints known to the staff or the Manager. People living in the home take part in appropriate community based activities and pastimes within the home or in the community, they enjoy relationships of The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 6 their choosing and have their rights and responsibilities as citizens upheld wherever possible. They said they enjoy shopping, walking, going on outings, going to pubs and restaurants, listening to music, doing activities in the garden, helping with household chores and preparing meals. People living in the home also enjoy a variety of meals and contribute towards menu planning within the home, ensuring that they have their likes and dislikes catered for. They can also be involved in and assist in the provision of and preparation of food wherever possible What has improved since the last inspection? What they could do better: Further information needs to be included in the contract so that people know what costs they should expect to pay and the services that this includes. The service could make sure there is more staff employed in the home and that additional care hours are allocated to people living in the home due to loss of day service places. The staff team are responsible for the domestic tasks and catering as well as providing care for people living in the home, which could restrict the time available to people for social activities. Although some of the people living in the home assist with domestic tasks, or are working towards more independent living, not all are able to do so. The service must make sure that stocks of controlled drugs are maintained in the controlled drugs register, so that the home complies with the Medicines Act 1968, the Misuse of Drugs Act 1971 and the guidelines of the Royal Pharmaceutical Society of GB, and so that service users can be confident their medication administration needs will be met in a safe and robust way. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 7 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 DS0000002815.V362857.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 DS0000002815.V362857.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): 2, 4 & 5 People who use the service experience good quality outcomes in this area. People using the service have their needs well assessed so they are confident they will be met and are given enough information about the home and its facilities before they make a decision to live there. Statements of terms and conditions of residency do not contain all of the information required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and Service User Guide that explains to the service users the services that are available to them. This does not include details of all of the current costs payable or additional costs that people may have to pay, for example a contribution for the use of the minibus. Information relating to the Commission for Social Care and Inspection was also found to be out of date. The document therefore needs reviewing, and adding to the service user guide, once complete. Case files were examined for three people living in the home. Each included a full assessment of the service users needs that had been completed before they came to live at the home. Individual care plans had been developed from the ‘Community Care’ care plan and the assessments. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 10 Discussions with people living in the home, a relative and staff supported the admissions process described by the manager and the fact that people had the opportunity to visit the home, have a meal or an overnight stay before making a decision to come to move in. The Mount DS0000002815.V362857.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 and 9. People who use the service experience good quality outcomes in this area. People living in the home have their individual needs well, but they could experience more autonomy in decision-making so that they can lead more independent lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person living in the home has an individual care plan, which describes how their assessed needs are met and is signed by them or their representative. Three care plans were seen as part of the case tracking process and were found to demonstrate clearly how people living in the home individual needs were identified and met. Care plans are evaluated each month and reviewed on an annual basis, or sooner if required. The council review is recorded on a North Lincolnshire Council Learning Disability review document, which asks the individual and the staff what they would like to discuss in the review meeting, shows who is invited, who The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 12 actually attends and then has a section at the back to show what action will be taken and by whom as a result of the meeting. Care plans seen had been updated in line with the decisions made at individuals reviews. There were also detailed risk assessment documents available in individuals files that covered a range of areas of risk in daily living, supporting people with the opportunity to become as independent as possible, whilst reducing the risks involved in this. One of the people spoken with said that they had been given more opportunities and were able to make their own decisions in the home, than where they had lived previously. In the bungalows people are quite independent and are working towards living independently at some point in the future. These people live fairly independently in the bungalows and enjoy deciding many of the daily issues for themselves, engaging in household chores and developing skills for more independent living, food preparation, shopping, as well as pursuing their own interests and hobbies, such as listening to music, football, going out, completing jigsaws etc. These people also question why things happen in their lives and sometimes go places or do things that put them outside of the risk assessments in place to help protect them. They are more able to understand the risk they take and generally require greater advice and support to live their lives. One said, “Staff support me when I need it, but most of the time I do things myself. The Manager has stopped me doing some things though, but always explains why and I understand the reasoning behind this, even if I don’t always agree. She doesn’t just tell us what to do.” Feedback from people living in the home and relatives indicated that they are involved in the review and development of care plans and that they have the opportunity to discuss any changes or wishes that they have in relation to their care. The second group of service users are those living in the main house that also make many decisions for themselves, about their daily activities etc. but may often only do so with the advice and support of staff. These people are also involved in a level of domestic and household tasks appropriate to their individual tasks. On speaking to people living in the home they said that they could approach staff with concerns or problems and that they felt they would be taken seriously. People gave examples of meetings that they were involved in and decision making, planning holidays, outings, activities, menu planning and their reviews The third group of people are those also living in the main house that are unable to communicate with the spoken word, but manage to make gestures The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 13 and use body language to express their like or dislike of what happens. They were observed to be relaxed, comfortable and interested in other people and events. Staff spoken to clearly express the view that some of these people are unable to make informed decisions of their own. However they were able to give good example of how choices could be offered to this group of people, to encourage them to be involved in the decision making process. They also demonstrated a good understanding of the way in which each individual would try to communicate with them and how they could encourage this. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 16 and 17. People who use the service experience good quality outcomes in this area. People using the service have opportunities to access a choice of leisure activities and are supported to maintain relationships. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Many of the people living in the home previously attended a local day service, which has recently closed. The home has developed a structured activities plan having spent time with the people living in the home and seeking their views as to what type of activities they would like to access. As well as providing activities some of the people living in the home wanted to maintain friendships with the people they had met at day services. The manager has looked into this and discussed this with other home managers to look into how this can be facilitated. As a result of this a barbeque has been planned for the bank holiday to give people the opportunity to meet up again. If this is successful The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 15 other events will be planned to give people the opportunity to meet up regularly. People living in the home have the opportunity to engage in a range of activities both in the home and in the local community. The garden of the home has rabbits and chickens allowing people the opportunity and experience of caring for a pet. In house activities include card making, craft, music, baking and cookery, manicures, painting, gardening, dominoes and bingo. A variety of visits are planned on a weekly basis and include day trips to, local garden centres, bowling, the seaside, shopping or Whelton farm. A pictorial and written record of these trips and events is maintained, offering people with communication difficulties a visual record of activities they have been involved in. People living in the home take part in some activities in the village, either visiting the local shop and pubs or going to church, some walk into Barton, others take the home’s transport or use the local transport. The people living in the home also have the opportunity to go on holiday and holidays have been taken in local seaside resorts. Staff also support people with home visits, when their relatives are not able to visit themselves. On the day of the visit some people were out on a bus trip, while others were involved in cooking, domestic tasks, games, watching television and listening to music. One person said, “I clean out my bedroom each week, but I’d really like to do some work in the office. Another said, “I always help in the kitchen washing pots, some are not capable of doing it you know. I clean my bedroom as well.” Both said they very much enjoy going out on the bus for outings. A monthly charge is made to all service users using the home’s transport and they sign an agreement to that effect. Discussion with people living in the home indicated that they enjoy going out into the community and have their own interests and hobbies, which are supported and encouraged by the home. One person living in the home described how he was supported to plan a meal in a restaurant for himself and his girlfriend. The range and access to a number of activities was further supported by relatives during discussion, but who also felt there was the potential to develop activities further by increasing staff levels. People spoken with said that they were very happy about the way that staff looked after them, they said that they felt safe and that their privacy, dignity and choices were respected. Observations of the interactions between staff and people living in the home showed that there is a good relationship between the two groups of people based on trust and friendship. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 16 The amount of contact between people living in the home and their relatives depends on the wishes of the individual and these are recorded in individual care plans. Relatives are welcomed into the home and staff also support people with home visits, when their relatives are not able to visit themselves. A full and varied menu is available in the home. This has been planned by the staff in consultation with the dietician and the people living in the home, based on individuals likes and dislikes. People living in the home spoken with said that the staff always ask them what they would like to eat and that the food was good. They also described how special meals or buffets were provided to celebrate birthdays and other special occasions, e.g. Christmas, barbeques Halloween etc. Staff and people living in the home explained that as well as the choices on the menu, additional alternatives are always available. Individuals have their weights taken on a monthly basis and nutritional assessments are also completed to ensure that people’s dietary needs are being met. Staff being observed supporting people with eating and drinking were seen to be doing so in a patient and dignified manner. The people living in the bungalows have individual weekly budgets, which they have agreed to combine. They are responsible for determining their weekly menus and shopping list, and for doing the shopping at weekends, as part of their independence training. Information obtained from the Manager reveals people living in the home are supported to go shopping each Friday and are guided by staff to purchase items to suit planned menus. Generally food consumed is according to service users choice and preference and they are satisfied with the outcomes. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience adequate quality outcomes in this area. People living in the home receive good assistance and support to maintain their personal and health care, so they are confident their needs will be met. Controlled medication stock level records are not appropriately maintained, presenting a possible risk to people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each individual care plan documents the visits and input each person has received from outside professional for example GP’s, chiropodist, psychologist, dentist, and optician. Staff and service users confirmed that they support individuals with all appointments. An assessment of consent for examination or treatment has also been completed with external professionals for each individual and an agreed action plan developed to support with this. The information in care plans showed that everyone living in the home has their own preferred routine and discussion with staff demonstrated that they had a good understanding of the wishes and choices made by each individual The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 18 and were able to describe their care needs and how staff were quick to offer help when it was needed, they also respected their wishes to be as independent as possible. The medication policy, states that people coming into the home can self – medicate if they wish to after a risk assessment has been completed and agreed. No one currently chooses to administer their own medicine. Since the last inspection all of the staff team have attended training on the Safe Administration of Medicines. The home uses the boots Monitored dosage system and there are two locked cupboards and a trolley available to store medication. At the previous inspection visit a requirement was made requesting that controlled medicines be appropriately stored and this has been completed. However, on examining the controlled medicines book, it was found that a running total of the stock levels was not being recorded, although the details of the controlled medicines was recorded and two people were signing for all medication that had been administered. A lack of recorded information about stock levels of medicines can contribute to the potential of it being abused and this going undetected. This had not been identified by an external pharmacist who audits the medication in the home on a regular basis. An immediate requirement letter was made in respect of this. The problem with the stock level recording was raised with the manager who discussed it immediately with staff, who said they had not recorded stock levels as they were unsure of how it should be documented as it was provided in three separate blister packs. A decision was made to record the total of all three packs as one entry and a deduction made each time the medicine was administered. Examination of other records were found to be accurate up to date and well managed. Discussion with service users, staff and the Manager reveals people living in the home are encouraged to take responsibility for their personal healthcare and they are assisted with personal support in a flexible, dignified way. People living in the home have varying levels of need in respect of personal and health care support, but all of those that are assisted with personal care receive assistance in privacy, and according to their preferences and wishes. Two people said, “I only need help with washing my hair and cleaning my back.” Another said, “I need help with shaving sometimes.” Others, it was reported by staff, require full assistance with personal hygiene and dressing etc. Care plans and diary notes seen confirmed the levels of support and assistance required and received. People living in the bungalows are self-caring and require only support, guidance and prompting with personal care and housekeeping. Their care plans and diary notes seen also confirm the support and guidance they receive. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. People using the service feel able to air their concerns without any fear of repercussions. The staff vetting procedure is sufficiently robust to ensure the safety of the service users. The judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home spoken with were able to describe how they could use the complaints process and were confident that they could talk to any of the staff if they had any problems. Some people living in the home are unaware of the complaints procedure and the manager has information of local advocacy agencies displayed in the home to help individuals with the complaints process. No complaints have been received by the home during the last twelve months. At the last inspection visit a requirement was made that staff should attend safeguarding training and this has been completed. Staff spoken with showed that they had a good understanding of their role in dealing with Safeguarding Adults issues and complaints. They are also able to demonstrate their understanding of the protocols, procedures and policies of both the North Lincolnshire Council and of Prime Life. A recruitment procedure and the manager oversees the recruitment process. An application form, two written references, a Criminal Records Bureau check and a Protection of Vulnerable Adults check are undertaken prior to a person starting employment. The risk of harm to people is minimised due to the stringent procedures in place. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 20 Two staff files were examined and these were found to be up to date Discussion with service users, relatives and staff and the Manager, and viewing of documents and procedures reveals service users and relatives have opportunities to make concerns and complaints known, and feel confident that they would be dealt with. One relative expressed some dissatisfaction of the area management of the organisation and their lack of response in responding to information relating to concerns about the previous manager of the home. People living in the home said they would talk to the staff or the Manager if they had any concerns or were unhappy about anything, and that they would do the same if they felt they or any other service user was being hurt in any way. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. People living in the home enjoy a clean, safe and homely environment, in a home that is suited to it stated purpose. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A full tour of the building was made and the home was found to be clean, well maintained and odour free. Bedrooms were personalised and decorated to suit individual tastes. Each bedroom has a suitable lock that can be used for privacy. Many individuals had personal belongings and furnishings in their rooms, making them feel homely and reflect the personalities of the occupants. One of the bedrooms is for two people, with privacy screens in place. People living in the home stated that they were happy with their individual rooms and several invited the inspector to visit their rooms. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 22 The washing machines at the home are all programmable to disinfection and sluicing standards and the machines have automatic feeds on them so the laundry staff do not have to have any contact with any caustic materials. There is also a smaller laundry facilities in the bungalows where the people can do their own washing to develop or maintain their independence skills. The home has several outside sitting areas, in well maintained gardens, which are accessible to the people living in the home. Communal areas were found to be light and airy and a choice of sitting areas were available to people living in the home. The house suits its stated purpose and provides a very homely atmosphere. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34,35 and 35. People who use the service experience good quality outcomes in this area. People living in the home are supported by staff who are supervised and undertake training. The staff vetting procedure is sufficiently robust to ensure the safety of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with the staff and the Manager, viewing of staffing rosters and allocated hours, indicates that there are insufficient hours being allocated each week to meet the needs of service users, and the manager is roistered to work on the floor without identified hours being available to fulfil her management role. At the last inspection a lack of training opportunities was identified. Staff spoken and feedback from completed surveys demonstrated that they had received considerable training over the last twelve months and this was supported by the staff training records. Staff training included: First aid, Non aggressive Physical and Psychological Interventions, Safe handling and The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 24 administration of medicines, LDAF, Moving and Handling, safeguarding of Adults, Fire and COSSH. Staff also described a specific training course that was tailored to meet their needs in meeting the specific behavioural difficulties of a person living in the home. This had been particularly useful in assisting them to identify triggers and precursors and support the individual in managing their behaviour more effectively. There has been considerable progress with the NVQ process and each member of the staff team are now registered to complete a National Vocational Qualification at level 2 or 3. Seven of the fifteen staff employed in the home have achieved this qualification, a total of 46 . Staff meetings are held every two months and staff supervision every three months, which does not meet the minimum standard of six times a year. Not all records were available from these meetings or had been signed by staff absent from the meeting, to demonstrate they were aware of any discussions/decisions made in their absence. However discussion with staff and feedback from surveys showed that they felt well supported in their roles and had enough information about people to meet their needs appropriately. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. People living in the home benefit from having a Registered Manager that is competent and is maintaining consistency within the service. Overall they experience adequate protection from harm under the home’s health and safety measures in place and the practices carried out to maintain service users’ and staff health, safety and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with the Manager reveals she has NVQ level 2 and several years experience of both working in the care profession and in a supervisory capacity. She worked as the Acting Manager for a year before being registered and is near the completion of the Registered Managers Award in Care. She has several years experience in a senior role working with Prime The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 26 There is a quality assurance system in operation for assessing the home’s quality of care, which involves surveying service users, relatives and staff and checking of documentation and care practices etc. in the home. The quality assurance system needs to be developed to look at individual development for each service user as a result of the service provided, and not just to focus on areas of managerial responsibility that indicate whether or not National Minimum Standards are being met. An in house quality assurance tool could support the organisations current system homes and be used by the manager as a tool to check that all systems within the home are working as they should e.g the error in recording controlled medicines stock levels (see Standard 20). Equally the manager needs time where she is roistered off the daily rota to enable her to have the time to fulfil her role. Infomation was received from Prime Life in the Aqaa document pre- stated fire safety, gas and electric engineer checks, and such as Legionella checks are all up to date. Areas of health and safety sampled during the site visit were fire safety, Legionella testing, and risk management. Records show fire drills are carried out each month, that extinguishers are checked annually Other checks made included verifying the last portable appliance test, and viewing certificates for gas and electrical safety checks. There are risk assessment documents in place to cover areas of the home such as the kitchen, fire safety, laundry use, and use of cleaning products etc. These are satisfactory. Standard 42 is adequately met. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 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 Score 3 3 1 X 2 X 3 X X 3 X The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5 Requirement The Registered Provider must develop a contract that meets the requirements of standard 5 and regulation 5. (This is a continuing requirement. Old timescale of 28/02/06 has not been met.) The Registered Provider must provide staffing in sufficient numbers as are appropriate for the health and welfare of service users, and it is expected that the Residential Staffing Forum recommendations be implemented, so that service users’ assessed needs are met. (This is a continuing requirement. Old timescale of 31/05/07 has not been met.) Timescale for action 30/06/08 2. YA33 18 30/06/08 3. YA20 13(2) The Registered Provider must 23/04/08 ensure that accurate records are maintained of the stock levels of all controlled medicines within the home. Stock levels should be altered accordingly to correspond to the amount of medication DS0000002815.V362857.R01.S.doc Version 5.2 Page 29 The Mount 4. YA33 18(2) 5. YA36 18(2) administered and the balance of this medication remaining in the home, each time the medication is administered, so that the home complies with the Medicines Act 1968, the Misuse of Drugs Act 1971 and the guidelines of the Royal Pharmaceutical Society of GB. People living in the home can then be confident their medication administration needs will be met in a safe and robust way. Immediate requirement made in respect of this. The Registered Manager should 30/06/08 ensure that regular staff meetings take place (a minimum of six per year) and are recorded and actioned. The Registered Manager should 30/06/08 ensure that staff have regular, recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day to day practice. The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 30 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 YA37 YA39 Good Practice Recommendations The Registered Provider must ensure the Manager begins a National Vocational Qualification level 4 within three months of approval as Registered Manager. The Manager should make sure the home’s quality assurance systems check that the needs of service users are being met to aid their personal development in line with the details of their care plan programmes, so that service users are confident the QA systems inform the business of any current and future requirements to meet their needs The organisation should consider how communication or communication systems can be further developed between area managers and relatives. 3. YA39 The Mount DS0000002815.V362857.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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