Inspection on 27/11/06 for The Mount

This inspection was carried out on 27th November 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Mount 23/06/09

The Mount 30/06/08

The Mount 06/08/07

The Mount 07/06/06

The Mount 24/10/05

The Mount 14/04/05

The Mount 05/10/04

The Mount 15/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Mount 226 Brettell Lane Amblecote Stourbridge West Midlands DY8 4BQ Lead Inspector Mrs Cathy Moore Unannounced Inspection 27th November 2006 07:40 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 DS0000025043.V319857.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. 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 DS0000025043.V319857.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Address 226 Brettell Lane Amblecote Stourbridge West Midlands DY8 4BQ 01384 265955 F/P01384 265955 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) Mrs Jenny Green Susan Foster Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 21.11.05 may be accommodated at the home in the category DE(E). This will remain until such time that the service users placement is terminated. 07/06/06 Date of last inspection Brief Description of the Service: The Mount is a residential home registered to provide 24-hour care and support for 18 people over the age of 65 although only 16 were accommodated at the time of this inspection. The property is a large 2 storey detached house situated on Brettell Lane, Amblecote and is within easy access by public transport. The home has recently been extended to incorporate a previously detached bungalow. There are gardens to the front and rear and car parking facilities to the side of the house. There are 16 single and 1 double rooms with the majority having en-suite toilet and hand wash basin facilities. There is a small lounge area with attached conservatory within the dining area, a larger main lounge and a further small lounge in the bungalow extension. Access to the first floor is via a lift or main stairway. The laundry is located in the cellar and is not accessible to service users. There is one assisted bath located on the 1st floor a shower room and new walk-in shower on the ground floor. Fee range for The Mount is £343- £368 per week. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector between 07.40 and 16.20 hours carried out this unannounced inspection. The inspection process assessed all of the key National Minimum Standards for Older People. Part of the inspection took place in communal areas where staff and service user involvement and daily routines could be observed. Three service users were case tracked this processes involves looking at their care in detail and where possible speaking to them and their relatives. Five service users and one relative were spoken to during the inspection. Three staff were spoken to in detail to gain their views on the home and its performance. Three staff files were examined to see how well the home manages recruitment of staff and staff training needs. The inspection looked at medication safety, maintenance, quality assurance processes and health and safety. The premises were partly assessed to include looking at three bedrooms, the lounge, conservatory, gardens, kitchen and laundry. What the service does well: What has improved since the last inspection? The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 6 It is extremely positive in that the home has improved considerably since the last inspection. A high proportion of requirements made following the last inspection have been addressed. Menus have been revised and have been produced in part pictorial form. All easy chairs have been replaced in the lounge and conservatory. The gardens have been tidied and the conservatory roof cleaned. Mechanical fans have been provided in the conservatory. The laundry equipment has been relocated to another room which is more accessible and appropriate. A washing machine with a sluice cycle has been purchased. New kitchen wall and floor cupboards have been purchased and installed. A new fridge has been purchased. A new ventilation system in the kitchen is in the process of being installed. Cleaning schedules have been produced and put into operation. Staff training has mostly been completed in all mandatory areas. At the present time all staff including catering and domestic staff are undertaking dementia training. The manager has produced and implemented a range of quality monitoring/ audit systems to improve standards and ways of working within the home. All requirements made concerning medication following the last inspection have been met. Certificates to prove safety were available during this inspection for the 5 year fixed electrical wiring testing, hoist and lift. 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 DS0000025043.V319857.R01.S.doc Version 5.2 Page 7 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 DS0000025043.V319857.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is adequate . Some evidence was available to confirm that prospective service users’ or their relatives’ are given information about the home prior to their admission. Some evidence was available to confirm that service users’ and their relatives are offered an invitation to visit the home to assess its suitability. A contract was available all files viewed but these did not all contain the required or current information. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the entrance hall copies of the home’s statement of purpose, service user guide and last inspection report were available for viewing. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 9 Two residents were not aware of the service user guide. One service user commented that her family had dealt with their admission and had seen to papers. Another resident said; “ My son dealt with my whole admission so if there was anything he would have seen this”. One relative confirmed that she had been given a copy of the home’s service user guide when she went to look around the home. No-one was able to confirm that they had seen a statement of purpose. There was no documentary evidence on file to demonstrate that all service users are personally offered the full range of information an example being; a statement of purpose, service user guide or range of fees. Three files case tracked held a terms and conditions document. These did not however, all detail the applicable weekly fee and/or room number. Two service users were not able to say how much their weekly fees are, but again confirmed that their families dealt with everything on their behalf. One relative confirmed that she knew the weekly fee rate and had been given a contract for her mother. Two service users confirmed that someone had visited them from the home before they came in. One of these whilst she was in hospital. A relative said; “The manager assessed Mum whilst she was in hospital”. An assessment of need document was available on all service users’ files viewed. At least two service users possibly have needs, one dementia, one mental disorder signs. The home however, is only registered to provide care to older people with personal care needs. To comply with their registration certificate the needs of these two service users must be confirmed and if needed a variation application must be made. From speaking to two residents’ and one relative it was confirmed that they or their representative had been given the opportunity to visit the home prior to admission. One resident said; “ I was not able to come. My son visited the home for me”. One relative said; “ I did not make an appointment I just came to the door and asked to look around for Mum as she was in hospital. They did not mind that I had not made an appointment”. There was however, no documentation to demonstrate that pre-admission visits are offered as a matter of course or any record of outcomes of relatives pre-visits to the home. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is good . A care plan was available on each file viewed. Some ‘fine tuning’ is needed to ensure that all needs are captured. Some improvement is needed to ensure that all service users health care needs are fully met. Medication systems have improved and are comprehensive. Service users feel that they are treated with respect. Last wishes are determined and recorded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All files viewed held a plan of care. These were well presented and covered a range of areas. One service user’s information obtained by from her social worker indicated that she may have mental health needs, yet these needs The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 11 were not reflected in her care plan for staff to act upon and monitor. For other service users there was no evidence in their care plans about their weight loss management. Service users seen looked well cared for and were appropriately dressed. Many of the females wore beads and rings. Their hair looked well maintained. Records of personal care delivery were seen to be maintained these showed when service users’ were washed, showered, teeth cleaned etc. One service user said; “ They look after us here”. A relative said; “ They do everything that Mum Needs”. There was evidence of healthcare visits examples being; the doctor and optician. One relative said; “ When Mum first came in here she had terrible pressure sores which she got when she was in hospital. The district nurses came everyday for two weeks. I could not believe how quick the sores got better”. There was evidence available to demonstrate that some service users are being weighed frequently. However, for one who is poorly no weight had been taken for some time and two had not been weighed since August 2006. It was noted that two service users have put weight on. One had gone from 6 St 11 llbs to 7 st 7llbs, another from 9.5 St to 10 St. Yet Two service users at least had lost weight. One in a year had gone from 11 St to 9St, another in eighteen months from 9St 10 llbs to 8 St. For these two service users there was no documentary evidence to confirm that the doctor had been specifically consulted about this weight loss. A range of risk assessment tools were seen to be in use in the home areas include; tissue viability, moving and handling and falls. Whilst most of these looked as though the scores were being calculated correctly one for (SC) was not in terms of nutritional scoring which may mean that observation and monitoring may not be as vigilant as it should. As with the last inspection, on entering the home a strong odour was detected. Continence promotion and management of incontinence is obviously not working for the service user concerned and other methods must be explored. Medication systems were assessed by the Commissions pharmacist in June 2006.She assessed the medications systems at this time to be adequate. A few requirements were made for improvement. It was pleasing to ascertain that these requirements have now been met. Medication systems were found to be good during this inspection. Staff have received training, all prescribed medications were available for the service users and medication records were seen to be well maintained. Staff observed during the inspection were polite and respectful to the service users giving them choices and explanations of processes. From exchanges observed between staff and service users it was clear that they have positive relationships. A relative said, “ Oh yes, the staff are very pleasant and polite to my family and to Mum. My brother who visits Mum regularly tells them that they all deserve a gold medal”. Service user meeting minutes dated 20 November 2006 read; “Residents were asked if they were happy with the care they The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 12 receive. All residents replied that they were more than happy. The carers were very good and polite to them”. Service users are addressed by the name of their choosing. The preferred name for each determined and recorded on their personal file. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. Generally service users feel the lifestyle experienced in the home meets their expectations. Service users are very much encouraged to maintain contact with family and friends. The home has an open visiting policy. Service users are enabled to exercise choice and control over their lives. Service users are offered a varied diet in pleasant surroundings. Food intake monitoring processes however, need some improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the morning service users were observed getting up at different times. Breakfast was offered throughout the morning to suit their preferred rising times. Pre-admission processes do include the determining of preferred rising and retiring times. One service user who was up washed and dressed in the lounge at 07.50 was asked if it was her choice to get up at that time. She The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 14 responded by saying; “ I like to get up at 7 o’clock. Once awake I don’t like staying in bed I never have”. The manager and staff are clearly trying to improve activity provision within the home. Planned activities are offered almost daily which is positive. During the morning a singing session was observed, a number of service user joined in this. One service user said ; “ We are going to play bingo this afternoon which I really enjoy”. During the afternoon a bingo session was held which the service users clearly enjoyed. Entertainment is purchased in at various times of the year. The home arranges festive events throughout the year at Christmas and Easter as examples. A record is not made as routine of service users names who participate in every day activities. This prevents effective audits of activity provision. The home does not have dedicated activity staff. Care staff provide activities. Dedicated activity time should be provided as additional hours to standard care hours. This would enhance one to one sessions for service users who would prefer this or who have needs that may need this input. The home has an open visiting policy which is detailed within the homes service user guide which says; “We welcome visitors at any time, but suggest that they avoid meal times to respect others whilst dining”. Service users spoken to confirmed that they receive regular visitors. One said; “ My son and his wife come and visit me. We can use the conservatory if we want for privacy”. A relative said,” I visit every morning. My brother comes in the afternoon and my other brother comes during the evening. We are all made to feel welcome”. She also said; “ We are taking Mum home for Christmas day”. Information relating to external advocacy services was available within the home for service users and relatives. All bedrooms viewed held a range of service users personal belongings demonstrating that service users can bring their own things into the home. This was further confirmed by speaking to service users and one relative. The service user said; “ My son has emptied my house. I’ve got a few things here though to remind me of home”. The relative said; “ We have brought some things in for Mum from her house”. It is positive that since the last inspection the manager has updated the homes menus which have been produced partly in pictorial form. The printed menus detail lunch, tea and supper. Breakfast is detailed on a board in the dining room. Service users can choose from a range of options every breakfast time including cereals, toast and or a cooked option. Lunch time was partly observed. The atmosphere in the dining room was pleasant and relaxed. Staff were on hand to give assistance and the tables were nicely laid. Two options were available for dinner and pudding. One service user just wanted a jacket potato which she ate and said she enjoyed. One male service user did not eat his lunch but asked for some toast instead which was provided. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 15 A discussion was held with the cook who confirmed that she tried to do all home baking, she said; “I do not agree with many ready made foods as they contain too much preservatives and E numbers. The pudding sponge and custard that day was home made with currants in it to add fruit. It is positive that during a service users meeting held in November 2006 all who attended were invited to discuss food. One shortfall identified is that a number of service users have lost weight yet as a matter of course their food intake is not being recorded which may hinder assessment by their doctor or dietician. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. The home actively tells service users and relatives about it’s complaints procedure. Protection processes need further development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the homes complaints procedure is included in the homes’ service user guide. A copy is also available in all bedrooms. It was positive when reading minutes from a service user meeting held in November 2006 that the subject of complaints was raised. The minutes read; “ Residents were asked if they knew who to go to if they had a complaint. Most residents knew that they could go to the manager or member of staff. Residents were informed that they all had a copy of the complaints procedure taped to their wardrobe, and if they could not see the procedure a copy large print was available”. One service user and one relative were asked if they were aware of the complaints procedure. Both confirmed that they had been given a copy but they had not read it. The service user said; “Have got but haven’t read yet”. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 17 One anonymous complaint was been received by the Commission in August 2006 that was sent to the provider to investigate, which was not upheld. Elements of the complaint were tracked during the inspection but again there was no evidence to uphold these. The complaints book was viewed which confirmed that no complaints have been received by the home since 2002. No allegations or concerns have been reported. It was said however, that one service user was aggressive to another some time ago. The information the inspector gained by verbal means was; “ N slapped D”. There was no evidence of behaviour monitoring processes and this incident had not been reported to other agencies as it should. It must be reported in retrospect. The majority of staff have received abuse awareness training. , there are only 3 staff who have not had this training which is being addressed. Procedures and policies were available within the home including Dudley Council’s procedures titled ‘Safeguard and Protect’. There was however, no evidence to suggest that staff have read Dudley’s procedures which are the ones that should be activated if there was an allegation or incident of abuse. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 Quality in this outcome area is adequate . The overall environment has some redecorating and replacement of carpet needs which need to be addressed. Hygiene standards in the home need further development and improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s atmosphere was found to be warm, friendly and positive. Generally, the upkeep of the home was found to be adequate in terms of decoration and furniture provided. There are areas which require attention examples being; the redecoration of bedrooms 2 and 6. Additionally the carpet in room 6 needs to be replaced as it has an iron burn mark. The home at the The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 19 present time does not have a programme of maintenance and renewal. This must be addressed. A full audit of redecoration and replacement needs will be needed to fully determine what is needed and for this programme to be developed. It is positive that some attention has been paid to the furnishings for instance all easy chairs in the conservatory and lounge have been replaced since the last inspection. Improvement has been made externally. The gardens looked at lot tidier than during the previous inspection It was noted during the inspection that the clocks in both the lounge and conservatory were showing the wrong time. This must be addressed. One service user did actually ask what the time was, if the clocks were right she would have not have had to ask. Similarly, as the home has 2 service users with dementia clocks showing the right time is important in terms of orientation. It is positive that ceiling fans have been provided in the conservatory to reduce heat in the summer months. All radiators in operation were seen to be suitably guarded. However, a concern was raised in that instead of the radiator in one bathroom being guarded it has been removed which may cause problems in cold weather. The Regulations dictate that the home must be ‘adequately heated’ which must be evidenced at all times. The large hot water pipes in the ground floor shower room have been covered to prevent burning however, two small pipes were still exposed. The manager confirmed and guaranteed that these pipes would be covered by the next day 28 November 2006. The manager has identified that lighting in the dining room is not adequate as it is too dim. She is in the process of looking for better lights to purchase for this room. As with the last inspection the ground floor corridor has a strong unpleasant odour emanating from one service users bedroom. There has been no improvement with this situation since the last inspection. This must be addressed and eradicated. It is extremely positive that the new laundry site is now in operation and a washing machine capable of providing sluice cycles has been purchased. The laundry however, is quite small, there is insufficient space to segregate clean and dirty washing. Red disposable bags to deal with soiled washing would enhance infection control processes in the home as these would prevent handling of these items. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user needs are met by the numbers of trained staff provided. The home has an excellent attainment level for staff achieving NVQ awards. Further improvement is needed to ensure that recruitment processes promote safety to service users. EVIDENCE: Three staff are provided during all waking hours plus the manager during office hours. Care staff are supplemented by cleaning and catering staff. Two waking staff are provided at night. Staff observed during the inspection were friendly and caring towards the service users. Staff spoken to were knowledgeable about the needs of service users. Positive comments were received about the staff including; “ The staff are very good” “The staff are kind”. Staff spoken to during the inspection were complimentary about the home one said; “ I love it here, it’s nice and friendly and all the staff get on”. Another staff member said; “ I think we all do a good job. The residents are cared for”. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 21 The staff must be congratulated on their NVQ attainment achievement. 12 of the 17 staff have achieved NVQ level 2 the remaining staff are working towards this award. A number of staff have also achieved or are working towards their level 3. Staff recruitment processes have improved since the last inspection however, one shortfall was identified in that one new domestic staff member was started in the home without a professional reference being obtained or even her POVA first being received. This poor practice could potentially place service users at risk. The full CRB for this staff member has now been received. This situation must not be repeated or the Commission will take action. Staff training is being well managed. A training matrix has been produced to show training received and the dates it was received. It is extremely positive that all staff including catering and domestic staff have been enrolled for the distance learning dementia care course The home has secured the services of one trainer evidence of insurance for this person was not however, available for viewing. Evidence was available to show that the new domestic staff member had received in-house induction. No new care staff have been employed of late the manager is aware of the new requirement in respect of Skill for Care induction standards. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is adequate. The manager has been approved as a fit person to be in charge of the home. Quality assurance systems must be complimented by formal monthly visits by the owner. Service users’ financial interests are being safeguarded. Staff are supervised regularly. Some improvement is needed in respect of health and safety. This judgement has been made using available evidence including a visit to this service. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Commission as a fit person to be in charge of the home has approved the manager. She has achieved her Registered Managers Award. The manager is very pro-active and has clear ideas of how to make improvements within the home. It is clear that she gives direction to the staff. One staff member said; “ I think the manager is very good. She is there for the residents. The residents find her approachable”. A relative said; “ The manager is very good if I raise anything she deals with it straight away. I don’t have to worry”. Quality assurance processes in the home have improved and developed significantly since the last inspection. Satisfaction surveys have been issued and a matrix produced of when others, to staff and relatives for instance, need to be issued. The manager has produced a monitoring process, which will be fully implemented soon and has audit mechanisms in place. What is letting these systems down is the inconsistent formal visiting by the registered person as no recent Regulation 26 visit reports were available to peruse. Two service user monies held in safe keeping by the home were checked, their balances against records. These were found to be correct. Records are maintained and two signatures verify transactions. It is positive that records were available to verify that staff are receiving regular, formal supervision. Two staff spoken to confirmed that they do indeed receive regular one to one supervision. To ensure that supervisions are carried out to the required frequency in future the manager has produced a supervision matrix so at a glance she can see who has received supervision and when and when supervisions are due. Since the last inspection health and safety within the home has improved in that certificates were available to confirm that the fixed electrical wiring is satisfactory and that the lift is being serviced properly. Certificates were also available to demonstrate that the hoisting equipment has been serviced within the last six months with the exception of the bath hoist. A lockable facility has been fitted to the kitchen door to prevent unauthorised access which is positive however, the door was open and the kitchen unattended when the inspection commenced thus placing service users at risk. Staff mandatory training is mostly up to date as mentioned in the previous section. Staff have since the last inspection received first aid training. The kitchen has also improved since the last inspection new cupboards have been installed and a new fridge purchased. A ventilation systems is in the process of being installed. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 24 Systems to improve food hygiene have also improved in areas such as food storage and date labelling. A cleaning schedule has been implemented however, at times recording to evidence cleaning is not consistent. The catering staff must monitor the fridge in the pantry as recorded temperatures at times were too high. The manager has produced a fire risk assessment for the home and ensured staff have received fire training and fire drill training. West Midlands Fire Service are due to inspect the home on 13 December 2006 and will assess the area of fire safety in more detail. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x 3 2 2 STAFFING Standard No Score 27 3 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 2 The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4,5 14(1)(a) 22(5) Requirement The registered person and manager must be able to produce documentation to evidence; That all prospective residents are offered a pre-admission visit to the home. The outcomes of each preadmission visit. Timescales of 07/07/06 not fully met. Where the service user has been offered a visit but has refused or is unable to visit this must be recorded. Details of relative visits must be made. Must be able to evidence at all times that the following have been issued to each service user or their relative; Statement of purpose Service user guide One of the above at least to detail the current range of fees for any given financial year. Complaints procedure. Timescale for action 01/12/06 The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 27 2 OP2 5 The registered person and manager must ensure that service user contracts or terms and conditions detail the applicable fee (for any given year) and room number. The registered person and manager must communicate with the Commissions Central Registration Team to determine the outcome of the variation made in the summer for one other service user who has DE(E) needs. A revised registration certificate must be requested. The registered person and manager must ensure that the pre-assessment pro-forma is signed and dated by the service user or their chosen representative. Timescale of 07/07/06 not fully met. The registered person and manager must; Ensure that no-service user is offered a place at the home who have needs which fall outside of the Old Age category. That the primary diagnosis for JR is confirmed in writing by a reliable person examples being; the doctor or social worker. The outcome of this to be provided to the CSCI. If it is MD(E) than a variation must be applied for to the CSCI central registration team. 03/01/07 3 OP4 14(1) 14(1)(a) 10/12/06 4 OP4 14(1)(a) 12/12/06 5 OP4 14(1) 15(1) 10/12/06 6 OP7 15(1) The registered person and manager must ensure that care plans are expanded to capture all needs and risks. Timescale of 07/07/06 not 05/12/06 The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 28 fully met. Example of this- possible mental disorder needs and the management of weight loss. 7 OP8 12(1)(a) 13(4)(c) The registered person and manager must ensure that all residents are weighed monthly or more regularly where there is a concern. Timescale of 07/07/06 not fully met. These weights must be recorded every time they are taken. Where unexplained or significant weight loss is identified than a referral must be made to their doctor or dietician. (For example JM). 8 OP8 12(1)(a) 23(2)(n) The registered person and manager must ensure that a suitable sit on weighing scale is purchased to allow weight monitoring for residents who can not sit on conventional ‘ sit on’ weighing scales. Timescale of 07/07/06 not fully met. Scales have been borrowed from another home but for at least 2 residents identified as not being able to stand on conventional scales there have been no records of their weight made since August 2006. 9 OP8 12(1)(a) 13(4)(c) The registered person and manager must ensure that all risk assessment scores for example nutritional assessments are accurately recorded and reflect the true scoring. DS0000025043.V319857.R01.S.doc 20/12/06 20/12/06 15/12/06 The Mount Version 5.2 Page 29 10 OP8 12(1)(a) 13(4)(c) 11 OP8 12(1a) 12(1(b) 13(3) The registered person and manager must obtain and put into operation other assessment tools for body mass monitoring where residents can not stand or sit on scales an example being the MUST tool. The registered person and manager must prevent any offensive odour in the home by making sure that each residents’ continence and personal care needs are met. That the flooring in bedrooms is replaced with one that is safe, non slip, easily cleanable and totally acceptable to the resident. The registered person and manager must ensure that any allergies are detailed in the allergy section at the top of the medication record or that ‘Nil allergies’ is entered. The registered person and manager must ensure that the names of each resident who participate in any activity be recorded. Timescale of 15/07/06 not fully met. This to include daily activities provided. 20/12/06 20/12/06 12 OP9 13(2) 20/12/06 13 OP12 16(2)(n) (m) 05/12/06 14 OP12 16(2(n(m) The registered person must 18(1)(a) ensure that 15 hours dedicated activity time is made available each week. These hours must be able to be evidenced at all times. Timescale of 15/07/06 not fully met. 10/01/07 The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 30 15 OP15 12(1)(a) 14(4)(c) The registered person and manager must implement food/fluid intake charts for each resident at least where a need or risk has been identified. Timescale of 20/06/06 not fully met. This to include residents who have lost weight, are of a low body weight or have irregular eating patterns etc`. A detailed budget for food must be provided to the manager The registered person and manager must produce the complaints procedure in a format appropriate to all residents’ for example pictorial. Timescale of 01/09/06 not fully met. 06/12/06 16 OP16 22(2) 10/01/07 17 OP18 13(6) 18(1)(a) The registered person and 27/12/06 manager must be able to evidence at all times that all staff are fully conversant with protection polices and procedures this to include Dudley MBC protection polices titled ‘Safeguard and Protect’. The registered person and manager must ensure that processes and monitoring documentation are in place for any resident who displays aggressive behaviour. (For example N). The situation between N and D must be reported to D social worker. The need to instigate protection procedures must be considered 06/12/06 18 OP18 13(6) The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 31 19 OP19 23(1)-(2) and assessed where any incident between residents occur. The registered person and manager must develop a programme of routine maintenance and renewal of fabric and decoration of individual rooms and exterior of the building. This requirement has been outstanding since 27/07/02. Decorating needs identified include the following; Redecoration of bedrooms 2 and 6. Carpet replacement room 6. Obviously not all rooms were inspected so to identify all decorating/ refurbishment needs a full documented audit must be carried out. 27/01/07 20 OP25 23(2)(p) The registered person and manager must; Take daily reading of temperatures in toilets and bathrooms where no heating is provided. Records of these must be made. Continue with plans for the replacement of lighting in the dining room as it is not bright enough. 10/12/06 21 OP26 13(2) The registered person and manger must ensure that the room adjoined to the laundry if freed up to allow more space to allow segregation of clean and dirty washing. That red disposable laundry bags are provided to enable soiled washing to go straight into the bags and into the washing DS0000025043.V319857.R01.S.doc 06/01/07 The Mount Version 5.2 Page 32 22 OP29 19(1)(11) machine to minimise handling. Ensure that all information contained in Schedule 2 of the Care Home Regulations 2001 in relation to fitness of staff employed is undertaken prior to commencement of employment. Timescales of 27/07/02 and 21/06/06 not fully met. (No professional references for cleaner). The registered person and manager must request that the homes trainer provides a copy of her liability insurance. The registered person must undertake at least monthly visits to the home and produce a report of their findings a copy of which must be given to the manager and be available for inspection. The registered person and manager must ask the homes trainer for a copy of her insurance certificate. The registered person and manager must ensure that the bath hoist is serviced and a certificate obtained to prove that this has been done. 10/12/06 23 OP30 18(1)(a) 25 26 (4)&(5)c) 15/12/06 24 OP33 27/01/07 25 OP38 25(2)(e) 15/12/06 26 OP38 23(2)(c) 12/12/06 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 Refer to Standard OP12 Good Practice Recommendations The registered person should seriously consider increasing the activity budget for the home. The Mount DS0000025043.V319857.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 DS0000025043.V319857.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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