Inspection on 26/09/05 for The Mount

This inspection was carried out on 26th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Mount 29/06/06

The Mount 16/05/05

The Mount 18/11/04

The Mount 14/07/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Mount School Hill Wargrave Berkshire RG10 8DY Lead Inspector Susan Cledwyn-Davies Unannounced Inspection 26th September 2005 9:10 X10015.doc Version 1.40 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 DS0000011007.V249695.R01.S.doc Version 5.0 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. 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 DS0000011007.V249695.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Mount Address School Hill Wargrave Berkshire RG10 8DY 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) 02170 886114 01270 886121 Majestic Number One Limited Mrs Sarah Ntshudu Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 37 beds up to 29 may also receive nursing care. Persons under the age of 60 will not be received except for respite care for periods not exceeding 3 weeks. 16th May 2005 Date of last inspection Brief Description of the Service: The Mount is a converted and extended Victorian house located on the northern bank of the river in the picturesque village of Warfield.The Mount accomodates up to 29 people needing nursing care and people needing residential care up to a total of 37 residents. The home is run by Majestic Number One ltd. Residents rooms are varied in size, many have en-suite facilities. There has been a lot of redecoration and new furniture provided. The communal areas being redecorated with new curtains and some new furniture. Specialised equipment has been obtained for resident comfort and safety. Residents are encouraged to bring in personal possessions and occasional furnishings to feel even more at home. Each room has a nurse call system and most have a TV. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9.10am and 2.45pm. Included in the inspection was a tour of the home, discussion with the manager, conversation with 6 residents and 6 staff. Records inspected included the staff rota, training, supervision and recruitment, quality assurance surveys, health and safety and complaints records. It is agreed that the term resident is used instead of service user, as this is the normal word used. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 All prospective residents have their needs assessed prior to moving into the home. EVIDENCE: Following the preadmission assessment the manager is starting to prepare an initial care plan that is sent back to relatives, confirming that the home can meet the care needs. This care plan should be returned prior to admission into the home. Once in place this will clearly demonstrate that the home can meet the needs plus ensuring that relatives are involved in the care plan. Preadmission assessments are taking place. Prior to admission visits to the home are encouraged. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of these standards were assessed on this visit. EVIDENCE: The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Residents have a variety of activities available. Contact is maintained with families and friends. Residents have a choice of meals. EVIDENCE: There is a new activities co-ordinator. During the visit she was busy preparing for the garden party to be held the next day. All residents and relatives are invited. The Friends of The Mount help and support the home and staff. The hairdresser was working in the home during the visit. The second floor bathroom was used. The room is light and spacious but there is no hairdressing sink. This makes it difficult for people with stiffness/frailty to have their hair washed, as they have to bend forward over the sink. It would be very positive and enabling for residents to have a hairdressing sink to wash hair in. Activities arranged are advertised on the main notice board. Relatives and friends are able to visit the home freely. All residents are asked for their choice of meals prior to the meal. The meal seen was tasty and enjoyed by residents. Since the last visit the kitchen The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 10 flooring has been replaced. This required bringing in a temporary kitchen to prepare meals while the kitchen was emptied and flooring replaced. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Residents and relatives are confident that their complaints will be listened to and acted upon. Residents’ legal rights are protected and are protected from abuse. EVIDENCE: The complaints record demonstrates thorough investigation of complaints and that relatives are happy with the outcome and satisfied with the care in the home. Residents can vote; both postal votes and trips to the polling station are used. There is good awareness of the protection of vulnerable adults. The POVA guidelines for multi-agency action are in place and staff have had POVA training. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Residents live in a safe and comfortable environment. The home is clean and pleasant. The exception is that the laundry needs an impermeable floor. EVIDENCE: The house is generally well decorated and furnished. New chairs have been purchased for the lounge; residents spoke of them being comfortable to sit in as well as smart. The corridor carpets in the extension is fairly recently changed but has a dark stain on one side. The manager is investigating this with the carpet supplier. The carpets in the upper floors of the old house are wearing and are due for change. A new kitchen floor has been fitted. This was a difficult task, needing a temporary kitchen to prepare residents meals while the kitchen was completely emptied for a few days. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 13 The laundry is apart from the main house. The floor of the laundry is concrete which is porous. To allow the floor to be cleaned it must have an impermeable surface. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. There are sufficient staff to meet the needs of residents. Staff have NVQ training. The recruitment practice is sound. Staff receive a range of training, there was no central record of training given to each staff member. EVIDENCE: Staff and residents confirmed that there was sufficient staff. Residents spoke well of staff, that they were cheerful and caring. The recruitment files of the last two staff employed were seen. Files showed good recruitment practice and were safely stored. The level of care staff that has achieved NVQ 2 training will be at 50 once the last group of carers have completed their training. Staff training is encouraged. Courses were seen to be taking place. There is a system for the central recording of training to ensure that each individual has received appropriate training and updates, plus ensuring that the minimum of 3 days per member. This is important for the manager to monitor training needs and training required. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 The manager is well respected and experienced. She has to complete her management training. Health and safety of residents is promoted. EVIDENCE: The manager is part way through the NVQ 4 in management and registered managers award. It is aimed for completion by the beginning of next year. This is made as a recommendation to ensure completion. Residents and staff spoke well of the Manager and had confidence in her. The provider has arrangements to check the quality of care and records kept. In August an audit of care plans took place and updates and work were left for the manager and staff to complete. This was largely to ensure that care plans are reviewed and that relatives and residents are involved in the process. The manager was making sure that these were being achieved. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 16 Staff supervision takes place. This was confirmed by staff and within records. The concern is that individual supervision is lower than necessary to achieve the recommended standard of 6 times a year. This year mostly one supervision has taken place. Residents are happy with care given but to ensure this continues supervision is an important part of providing quality care. There are very good records demonstrating that the servicing and maintenance of the home is well regarded. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 2 X 3 The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 18 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 2 Standard OP26 OP36 Regulation 23 18 Requirement The laundry floor needs to be impermeable. That all staff receive individual supervision six times a year. Timescale for action 01/12/05 01/04/06 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 3 Refer to Standard OP12 OP30 OP31 Good Practice Recommendations That serious consideration is given to providing a hairdressing sink. That a central training record be maintained. That the manager completes the NVQ 4 in management. The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Mount DS0000011007.V249695.R01.S.doc Version 5.0 Page 20 - 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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