Inspection on 29/06/06 for The Mount

This inspection was carried out on 29th June 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 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 26/09/05

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 Stephen Webb Unannounced Inspection 29th June 2006 10:00 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 DS0000011007.V294891.R02.S.doc Version 5.1 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. DS0000011007.V294891.R02.S.doc Version 5.1 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) 0118 9402046 0118 9404909 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 DS0000011007.V294891.R02.S.doc Version 5.1 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. 26th September 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 Wargrave. The Mount accommodates 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 vary in size, though 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. Fees, at the time of this inspection ranged from £500-£675 per week, with additional charges for incontinence supplies, chiropody, and hairdressing. DS0000011007.V294891.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.00am until 6.45pm on 29th of June 2006. The inspection also included reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversations with service users, relatives, management and staff at the unit, and from fifteen returned service user questionnaires, some of which were completed by relatives with or on behalf of service users. The inspector also toured the premises and had lunch with service users. The home had a welcoming atmosphere and created a positive first impression. What the service does well: The home provides readily available information about its service and undertakes a thorough assessment process prior to admission. Care planning is effective and detailed. The initial care plan is sent to the next of kin where appropriate to ensure accuracy and that any additional relevant information is obtained. Healthcare is managed effectively for the most part. Pressure sore audits are in place and appear effective. The manager also has a care plan audit system in place. Medication is well managed within an effective system. The home addresses service users dignity and privacy appropriately, and the majority of service users felt their needs were met effectively. The home employs an activities coordinator for thirty hours per week and operates a varied programme of activities, entertainment, seasonal events and outings to places of interest and other homes in the group. Service users can exercise choice in their day-to-day lives including whether to take part in the activities provided. The activities coordinator spends time oneto-one with individual service users to ensure their needs are provided for. The spiritual needs of service users are met through visiting clergy as required. Visiting is flexible and a number of visitors were seen in the home of the day of the inspection. Feedback from a sample of relatives was mostly very positive. DS0000011007.V294891.R02.S.doc Version 5.1 Page 6 An appropriate system was in place for the management of service user funds where they are unable to manage these for themselves. The home has an appropriate complaints procedure and feedback indicated it to be effective. The procedure is widely available within the home, and the majority of service users knew who to speak to if they had any concerns. The majority of the physical environment was attractively decorated and homely. Furnishings and carpets were satisfactory throughout. One bathroom had been redecorated to a good standard and had been made more homely with the addition of decorative items.(However, see below re some of the bathrooms and the laundry). The main garden area was large and very attractively planted. It provided seating and umbrellas for the provision of shade. A number of service users were observed using the garden including those in wheelchairs, supported by the activities coordinator and other staff. Staff recruitment appears to be effective and the home does not experience excessive staff turnover. Recruitment procedures are mostly appropriate, though the manager is advised to obtain the latest Home Office guidance on recruitment from overseas to ensure that the relevant records are seen and copies retained. The home is effectively managed and there is a quality assurance system in place, which includes consulting service users and others for feedback. The views of service users have also been sought on specific subjects such as meals, following receipt of some complaints, which is good practice. Service users and relatives also have opportunities to air their views in scheduled meetings with the manager, and felt better informed, more recently, about the development plans for the home. What has improved since the last inspection? The manager is introducing an emotional wellbeing assessment format, which is a positive addition to the assessment process. Since the last inspection, there had been a number of complaints about aspects of the meals provided. The home has responded positively with feedback questionnaires and monitoring, and positive changes have been made to improve the food. This was confirmed by service users and relatives. The menus included an appropriate range of meals and offered choice at every meal. The inspector observed the available choices being actively offered during the inspection and service users confirmed this to be the norm. Special diets are catered for where necessary. DS0000011007.V294891.R02.S.doc Version 5.1 Page 7 The laundry had been provided with appropriate impermeable flooring to facilitate effective hygiene maintenance. The home continues to a make good progress with the level of NVQ attainment, and the manager has attained her Level 4 and Registered Manager’s Award. What they could do better: There is a need to provide documented evidence of a regular cycle of internal review of individual care plans and to pursue copies of minutes where placing authorities carry out statutory reviews. There is the potential for further development in terms of adaptations for service users with impaired sight and hearing, and those who experience degrees of confusion. It is hoped that these issues will be addressed during the development works for the new dementia unit. There is a need for improvement of some aspects of healthcare records. Any staff who have not received Protection Of Vulnerable Adults (POVA) training must be provided with this as a priority to maximise the protection of service users. A system for providing periodic updates to this training is also necessary to ensure that staff remain up-to-date and aware of the issues. All but one of the bathrooms were in need of redecoration to bring them up to a good standard. They were not attractively decorated and lacked homeliness. The exterior of the separate laundry building was in urgent need of the application of appropriate weatherproofing, as the current surface was beginning to break up and could present a health and safety hazard with further deterioration. Some residents and relatives were concerned that the planned development of the dementia unit may have a detrimental effect on the physical environment provided in terms of the current choice of two lounges and the overall available communal space. The manager must ensure that due consideration is given to maintaining or improving the communal facilities as the result of the planned developments. The manager should keep the staffing levels and deployment under ongoing review to ensure that service users needs continue to be met effectively. Although there is a quality assurance system in place, there is a need to produce a summary report of the findings of QA surveys to those who took part, to inform them of the outcomes and encourage future participation. DS0000011007.V294891.R02.S.doc Version 5.1 Page 8 There is also a need to produce an annual development plan for the home. The manager needs to establish a system for copying accident records onto the relevant case record files as well as maintaining the current collective record, which facilitates effective management monitoring. 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. DS0000011007.V294891.R02.S.doc Version 5.1 Page 9 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 DS0000011007.V294891.R02.S.doc Version 5.1 Page 10 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): 1, 3, 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service demonstrates a thorough approach to pre-admission assessment and available records support this. The new “Traffic Lights to Wellbeing” format is a positive addition to the range of assessment tools in use, addressing the emotional wellbeing of prospective service users. Standard 6 is not applicable. The home does not provide an intermediate care service. EVIDENCE: The home provides a statement of purpose and service user guide and these and other documents are readily available on display in the homes entrance hall. Available documents included a copy of the previous inspection report, activities and events diaries, copies of the current menus, details of events in the locality and a schedule of the planned works to develop a dementia unit at the home. This is good practice. DS0000011007.V294891.R02.S.doc Version 5.1 Page 11 The manager has a comprehensive assessment document which when completed includes a good initial care plan. The documents completed include relevant risk assessments and a Waterlow pressure sore risk assessment. The manager visits the prospective service user at home or in hospital to carry out the assessment, and they or their relatives are invited to visit The Mount at least once prior to admission. This was confirmed in conversation with service users and relatives. The initial care plan is sent to the prospective resident or their family for approval and to gain any relevant additional information. This is good practice. The files examined also included transfer documents from a previous placement in one case, and reports from other professionals. The manager is introducing an additional document called “Traffic Lights To Wellbeing” which is a very useful assessment of emotional health, and could signpost the need for additional support input in some cases. Again this is an example of good practice. DS0000011007.V294891.R02.S.doc Version 5.1 Page 12 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): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective care planning system, though the system and recording of reviews needs to be improved. The manager’s audit checklist of the care plans is a useful monitoring tool. The healthcare of service users is managed effectively for the most part, and the home has good relationships with external healthcare professionals. There is room for potential further development in the area of adaptations to assist service users with impaired sight and hearing, and those who experience confusion, and these should be addressed as part of the plans to develop the service over the next nine months. Some aspects of healthcare records need improvement including the use of photographs of pressure sores in all cases, though the home does have a pressure sore monitoring system in place. Any recording formats remaining within care files should be fully completed, using “not applicable“ where appropriate. The delays in the planned works to develop the dementia care unit have allowed service users and relatives more time to come to terms with the DS0000011007.V294891.R02.S.doc Version 5.1 Page 13 changes and raise any concerns they may have. Additional progress meetings with service users and relatives are planned. The home has an effective medication management system in place and administering staff receive appropriate training. The vast majority of service users are satisfied with the care they receive from the staff and feel that their dignity and privacy are respected. EVIDENCE: As noted above, an initial service user plan is drawn up on completion of the preadmission assessment, based on the information provided at this stage. The manager is introducing a new emotional well-being assessment, which will provide additional useful indicators to areas of possible support needs. The full care plan is then devised once the unit becomes familiar with the service user and they have the chance to settle into the home. These ongoing care plans are drawn up by the nursing staff, in consultation with care staff. The manager had completed audit checklists of the care plans in March 2006, and developed an action plan to address any shortfalls in information or practice. This included identifying that statutory and interim reviews had not routinely been documented, though informal reviews of the care plans are ongoing. Some of the existing review documentation was not being completed, and this was evident from the files sampled. Reviews of service user care plans must be carried out in accordance with Standard 7 and Regulation 15, and records must be retained of this process, and the outcome in terms of any changes to the care plan. In one case the manager confirmed that annual statutory reviews had been undertaken by the placing authority, in 2005 and 2006 but no copies of review minutes or other documents were available to evidence this. Of the current service users, seven were using cot sides at night to reduce the risk of falls from bed. The manager reported that the next of kin were always consulted about the use of cot sides and that consents were now on file, following the emergence of the issue during her care plan audit. This illustrates the positive benefits of such a management audit system. An unsigned consent form was present in one file for a service user who does not use cot sides, which could give the impression of a failure to obtain consent. If an element of the recording system is not relevant in an individual DS0000011007.V294891.R02.S.doc Version 5.1 Page 14 case, it is recommended this element of the format is removed from the file, or that an entry is made within it to indicate that it is not applicable. The deputy manager provides a monthly pressure sore audit report to the manager. At the time of inspection two service users had pressure sores, one at level 1 and one at level two. Both were responding to treatment. In one file, no photographs of the reported pressure sores, (now virtually healed), were present, to indicate the progress of treatment. It is not best practice to rely only on sketches, and photographs should be used in each case, to assist in the evaluation of progress. The home has positive relationships with a range of external healthcare professionals including CPN, psychologist, speech and language therapist, GP and district nursing services. The manager reported that at the time of inspection, the home was not experiencing any problematic behaviour management issues. Service users with hearing and sight loss are supported by annual visits from the audiologist and six-weekly optician visits to the home. The manager confirmed that the home did not have a loop system installed anywhere. It is recommended that the manager assess whether any of the current service users would benefit from the installation of an induction loop system, in consultation with the audiologist. Appropriate ramps are placed at changes of floor level throughout the home, to facilitate ease of mobility about the home by service users, especially those who mobilise via wheelchair. The upstairs rooms in the main house are served by a passenger lift. At present the home does not have adaptations such as individually coloured doors and doorframes to assist service users with sight loss or developing confusion, to find their way about the home. The manager said that this would be considered during the planning for the proposed dementia unit. It is proposed that the dementia unit will be established as a separate unit within the home, incorporating the ground floor extension areas at the rear of the home, and with its own lounge, dining room and kitchenette provided. The unit will be staffed by a separate, suitably trained team, and will initially offer eleven beds, increasing later to seventeen. Following feedback from service users and relatives, the decision was taken to extend the transition period for the development of the dementia unit to between six and nine months, and this has gone some way to alleviating some of the concerns of relatives and service users, who were concerned about the speed with which the changes were originally planned. DS0000011007.V294891.R02.S.doc Version 5.1 Page 15 Relevant parties have been kept informed via an initial letter and subsequently through an open meeting at the home. It is suggested that further meetings be held to report on progress during the changes. The home has an effective medication management system in place, with an appropriate medication audit trail. Records of medication are well maintained and it is administered only by staff who have been trained. Service users confirmed that treatment by medical professionals is provided in the privacy of their bedroom behind a closed door. Other aspects of their personal care and support are addressed with appropriate regard for their privacy and dignity. Of the sixteen service user questionnaires completed, (Some with the aid of relatives), fifteen felt that they received the care and support they needed, either always (8), or usually (7). Two service users expressed their satisfaction at the care provided, though another one felt that the staff working on Sundays, were less proactive. DS0000011007.V294891.R02.S.doc Version 5.1 Page 16 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, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home employs an activities coordinator and provides a good range of activities and outings, as well as encouraging social links with the service users in the organisation’s other homes. Visiting is encouraged and relationships with the majority of service users and their representatives are positive. Service users are enabled to exercise choices in their day-to-day lives, though one or two felt that at times their options were limited by staff availability. The majority of service users are now happy with the food provided. The home has responded positively to some issues previously raised about the meals, and has sought the views of service users about this directly, through surveys and via the residents’ meetings. EVIDENCE: The home employs an activities coordinator for thirty hours per week, who leads most of the activities. Several positive comments were made about the work of the activities coordinator. DS0000011007.V294891.R02.S.doc Version 5.1 Page 17 There are a number of planned seasonal events throughout the year, which are posted on a notice in the entrance hall. There is also a month-by-month activities diary posted here, and both are also posted on the residents notice board. The home has access to a shared minibus for outings and trips to other homes operated by the providers. Recent outings have included Windsor Great Park, the river at Hurley, Caversham and Marlow. Activities are scheduled, most mornings and afternoons from Monday to Friday for those who wish to take part. The range of available activities includes flower arranging, hair and beauty, manicures, quizzes, board games, church services, craft sessions, outings, sherry mornings, reminiscence, pat-a-dog, exercise sessions and tea parties. The activities co-ordinator also sees service users one-to-one, particularly those who take little part in the planned activities to try to ensure they have their needs met. Records are kept of individuals’ participation in activities, which indicate increased involvement for some service users over time, and also highlight those reluctant to take part. One service user commented that they would like more varied art/craft materials to be provided. As part of her engagement with individual service users, the activities coordinator also tries to compile a family tree, with support from family where necessary, which can suggest ideas for areas of interest and subjects for conversation to assist with maintaining orientation. Service users spiritual needs are addressed through visiting clergy as required by the needs of the current group. Visiting to the home is unrestricted, with some service users receiving daily visitors, and about 50 having regular visitors. Privacy can be provided within a service user’s bedroom or perhaps in the garden, or visitors can see their relative in the lounge or dining room. Some of the service users had been assisted by their relatives to complete the service user questionnaire. A significant number of relatives were observed to visit during the inspection, and a sample were spoken to by the inspector to seek their views about the home and the care provided. The feedback was very positive. One relative said that if they had to choose a home again, they “would choose here again”. Other comments included, “the staff are kind and patient”, “The food has improved now in response to complaints”, “ I liked the manager’s approach and attitude” and “they keep me informed”. A relative also commented that privacy and dignity were managed well by the staff, and one felt that her relative was well looked after and comfortable. One said that her relative was unable to take part much in activities, but was DS0000011007.V294891.R02.S.doc Version 5.1 Page 18 involved and included well by the staff when possible. It was also noted that due attention was paid to the need for a special diet for one service user. A small number of relatives and residents did have negative feedback about the quality of the meals and aspects of the care, including insufficient exercise provision, and lack of staff time to talk. None of the current service users is able to manage their own personal allowance. The home manages this on their behalf, unless family wish to do so, or the individual is subject to court of protection. There is a written procedure for managing service user funds and all monies are retained separately in zip bags with receipts, and secured in a safe. Records are maintained on individual personal allowance record sheets, with two signatories including the manager. The manager and administrator audit these records monthly. Family are asked to retain any excessive funds that may accumulate. Service users are supported to make choices on a daily basis around meals and other areas, though one or two wanted more choice over getting up times. The inspector observed staff attending to service user dignity effectively and actively offering choices. Staff were clearly engaged with service users and there was evident warmth in the interactions observed. Several of the service users referred to the manager by her first name, and made positive comments about her accessibility and having time for them. Service user privacy and dignity is also aided because all but two of the bedrooms are single occupancy. The two double rooms are let as singles unless a request to share is specifically made. However, none of the bedroom doors is fitted with a lock for those who might be able to manage this. This issue was not raised by anyone during the inspection. The home is operating around a four weekly cycle of menus, which are kept under review seasonally. Laminated copies of the current menus were available in the entrance hall. The menus include choices at all meals and the inspector observed service users being offered these choices by the staff. Service users confirmed that this was normal practice. The menu is designed and prepared with due regard to diabetic diet (three service users), apart from the desserts, where suitable alternatives are provided. One service user is on a weight-reducing diet, provided by a dietician, which was listed in the kitchen. DS0000011007.V294891.R02.S.doc Version 5.1 Page 19 It was noted that service users are consulted about the food in residents meetings and the minutes posted on the service user’s notice board confirmed this. The menus have been improved following feedback from service users about previous concerns. The chef uses a high proportion of fresh ingredients. Feedback forms were also given to a sample of service users, daily during June in response to the concerns previously expressed about the food, which is good practice. The manager and deputy also quality checked the meals over the period of a month. The main dining room is a pleasant environment with fresh flowers, tablecloths, cruets and glasses provided. DS0000011007.V294891.R02.S.doc Version 5.1 Page 20 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective complaints procedure, and there is evidence that complaints are addressed effectively. It is good practice that the procedure is widely available to service users and visitors to the home. The home protects service users from abuse effectively, though there is a need for POVA training to be provided to those who have not received it, and to establish a programme of periodic update of this training. (Requirement made under Standard 30). EVIDENCE: The home has an appropriate written complaints procedure, which is posted in each bedroom and available in the home’s entrance hall. The complaints index record includes brief details of any complaints raised, and Indicated two matters since the last inspection, one relating to food and the other regarding clothing damage. Both appear to have been resolved appropriately. Conversations with a sample of service users and relatives indicated no current complaints, though the previous concerns about the food were mentioned, with the comment that improvements had been made as the result, and one relative was not fully happy with some aspects of the care provided. DS0000011007.V294891.R02.S.doc Version 5.1 Page 21 Of the sixteen responses to the service user questionnaire, fifteen were clear about whom they would speak to if they were not happy, and fourteen were clear about the complaints procedure. The home has a written policy/procedure on the protection of service users from abuse. However, at the time of inspection only about half of the staff had received recent POVA (Protection Of Vulnerable Adults) training. The manager must prioritise this training for any staff who have yet to receive it, and should establish a system for periodical updating of the training in this area. (Requirement made under Standard 30). As already noted, the home has an appropriate system for managing service user funds to protect them from financial abuse. DS0000011007.V294891.R02.S.doc Version 5.1 Page 22 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, 20, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. For the most part, the premises were satisfactorily decorated and furnished, and had a homely style, though some of the bathrooms require attention to improve their décor. Plans are being devised for improvements to the environment as well as for the development of a dementia unit. There are also plans to improve the available parking facilities. The garden is a very positive facility for the home, and there are plans for further development here also. However, the external laundry building is not satisfactory and requires structural attention to maintain health and safety. EVIDENCE: The majority of the premises were satisfactorily decorated and the carpets were in good condition throughout. The majority of the furniture was also satisfactory. The entrance hall is light and welcoming and there is a wide range of information provided there, about the home and the area. DS0000011007.V294891.R02.S.doc Version 5.1 Page 23 Some consideration should be given to the provision of a board with staff photos and designations, to assist visitors in identifying individual staff and who is in charge of the home at any point. One of the bathrooms had been refurbished to a very good, homely standard, though others remain in need of upgrading to a similar standard. Some of the baths are equipped with hoists, which were appropriately serviced and maintained. The main lounge was an attractive, homely and busy room, used by many of the service users during the day and also by a number of visitors, especially during the afternoon. There is a second lounge/dining room at present, which will be incorporated into the dementia unit when it is established. Some concern has been expressed about the reduction in communal space, in terms of the loss of choice that will result, and the possibility of providing a new second lounge space should be considered, perhaps via the addition of a conservatory. The provider should ensure that the development plans do not lead to a reduction in available communal space for service users. The main dining room is an attractive space and the tables are decorated with fresh flowers, and provided with cruets, place mats and tablecloths. A hairdressing sink had been ordered in response to a previous inspection recommendation, but the wrong item had been delivered. This was to be exchanged for the correct type and was then going to be installed. The laundry flooring had been replaced with suitable impermeable flooring following a requirement from the last inspection. However, the exterior panelling of the stand-alone laundry building was delaminating, as it was not of weatherproof construction. The building was therefore shabby and in danger of further deterioration, and must be provided with an appropriate impermeable material to maintain it’s integrity and electrical health and safety. The home has a large garden, which is attractively planted and well maintained. It includes paths, a large lawn, shrubs and planted borders, and some mature trees. There are plans to increase the available parking provision, which is currently insufficient at busy times. When the new dementia unit is developed a section of garden will be securely fenced, exclusively for the use of residents in the unit, enabling them to use the area without direct staff supervision if they are able. DS0000011007.V294891.R02.S.doc Version 5.1 Page 24 The provider should consider the provision of some sensory planting and raised beds, to provide sensory stimulation to service users and possible opportunities for limited gardening activities. A number of service users were observed making use of the garden on the day of inspection, including some wheelchair users who were assisted to access the garden by staff. There was various seating and tables available in the garden as well as some sun umbrellas to provide necessary shade. There are unused areas of garden and a mature orchard area which might be possible to incorporate within the areas accessible to service users, with some development work. A sample of the required health and safety service certification was examined and found to be up to date. The home has an in-house handyman, trained to carry out the annual testing of electrical appliances, which enables any service user’s electrical items to be tested on arrival. Discussion with service users about the premises elicited mainly positive comments, though some anxiety was still evident about the planned dementia unit and how this would impact on existing service users in terms of their amenities. As already noted, the proprietors would be wise to hold further residents and relatives meetings to keep people informed of progress and explain how their facilities are to be maintained. Following previous anxieties about the development of the dementia unit, the plans have now been delayed and will be phased in over six to nine months, with eleven dementia beds initially, rising eventually to seventeen. The unit will encompass the single story extensions to the rear of the home, leaving the older main house for those less frail and confused. It would be helpful if copies of the plans for these developments were supplied to CSCI, once they are finalised. One service user was happy that her room was close to a toilet as she was not in an en suite bedroom. Others commented positively on their bedrooms. A relative commented that any maintenance issues raised were attended to, and that there were no unpleasant odours in the home. All bar two of the bedrooms are single occupancy. The two double rooms are only shared if this is requested by both parties. As noted earlier, there are plans to enhance the provision for service users with impaired eyesight or hearing, and those who experience confusion, as part of the planned developments. DS0000011007.V294891.R02.S.doc Version 5.1 Page 25 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of service user feedback about the staff was positive. The manager needs to ensure that staff numbers and deployment remain sufficient to meet the needs of service users at all times, and must ensure that key training is provided to all staff. EVIDENCE: When asked whether staff are available when they need them, two service users replied this was “always” the case, ten replied usually and four indicated only sometimes. The individual comments made included that the home is sometimes short of staff, two said that there were no staff available in the lounge at times and one commented that the staff are often too busy to talk with them. One service user said there were enough staff most of the time. One relative also felt that at times the home appeared short of staff. This might indicate a need to review staff deployment and or staffing levels. At any event, once the separate dementia unit is established there will need to be sufficient staff deployed in each unit to meet the needs of service users, rather than an overall staff team, working across the whole building. DS0000011007.V294891.R02.S.doc Version 5.1 Page 26 Staff turnover since the previous inspection in September 2005 was eight staff, six of whom have been replaced and the remaining two will be re-advertised, following recent unsuccessful interviews. The manager is also advertising for a full-time administrator to cover maternity leave. The manager is also going to start recruiting for the new dementia unit, and for a small in-house bank of staff who could provide cover for sickness, maternity leave and training attendance. One or two overheard staff comments indicated some levels of friction around roles and/or performance, which the manager may need to address. Of the current staff team, seven are RGN’s, one is undertaking NVQ level 4, six have NVQ level 2 and four are undertaking this. Four staff remain to do their NVQ. Examination of a sample of recent staff recruitment records indicated that recruitment practice was appropriate for the most part, although some paperwork, relating to work permits/right to work in the UK, for staff from overseas was not available. The manger is recommended to obtain the current booklet from the Home Office on overseas recruitment, to ensure that records and practice meet the current legislation. Staff receive an induction, which includes the core areas including complaints. All staff have received moving and handling training from an accredited inhouse trainer within the provider organisation. The manager, deputy and some carers have already received training on working with dementia and this will need to be provided to all staff working in the dementia unit. There is a need for POVA training to be provided to staff who have not received this recently and for a system of periodic update of this training for all staff, to be established. DS0000011007.V294891.R02.S.doc Version 5.1 Page 27 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, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is managed effectively, by the home manager, and there is a clear chain of command and communication. A range of quality assurance and consultation systems is in place, operated both by the provider, and within the unit. There is evidence of changes and improvements being made as a direct result of feedback obtained. There remains a need for improved feedback from quality assurance surveys, to participants, and for the provision of an annual development plan arising from the cycle of review and consultation that is already in place. The home’s collective accident recording and review system is effective, though copies of individual accident records need to be filed on service user care files. DS0000011007.V294891.R02.S.doc Version 5.1 Page 28 EVIDENCE: The manager achieved her NVQ 4 and Registered Manager’s Award in February 2006. She is an established and experienced manager and there are clear lines of accountability and reporting within the hierarchy. The providers have devised an internal quality-monitoring tool, which provides a detailed check on the performance of the service. Questionnaires had been provided to family visitors between February and April, which had indicated positive feedback. One service user said they had just received quality assurance questionnaires from the home, prior to the inspection. The manager confirmed that “delivery of care” questionnaires had just been distributed to service users and some relatives, to enable them to support service users with completion. A deadline should be set and once the feedback is obtained, the results must be collated into a summary report and made available to those who were consulted. This demonstrates openness and should encourage future participation. A detailed annual development plan for the service, should be produced. It is likely that this will focus largely on the planned development of the dementia unit, but it should cover a broader agenda than this to address all factors impacting on the outcomes for service users. Service users are also consulted via the quarterly residents meetings, which are minuted. The most recent minutes were posted on the residents’ notice board. As already noted a sample of service users were also asked to complete feedback forms about the meals, following previous complaints. Positive changes were made to the menus as the result of direct feedback received, which were acknowledged by service users. This is good evidence of effective consultation. The home also has a family and friends group which meets approximately every eight weeks. The minutes of these meetings are posted on the residents’ notice board. Relatives and service users were also invited to a meeting to hear about the proposed development of a dementia unit at the home, following initial concerns, and changes to the planned timescale were made as a result of representations received. One relative commented that the meeting had addressed their concerns, though another still had reservations about the proposed development in terms of the effect on existing service users. DS0000011007.V294891.R02.S.doc Version 5.1 Page 29 The provider also monitors the operation of the home through regular Regulation 26 monitoring visits, for which the reports were available in the unit apart from that for March 2006. It was later clarified that this report had been present but was dated 18th April. As noted earlier in this report, the home has an appropriate system in place for the management and safe-keeping of service users’ money The home has a detailed collective accident record in place, with records separated by month for ease of monitoring, and there are monthly analysis returns forwarded to the providers. However, at present there are no individual records of accidents on service user care records as required. The manager must establish a system for these, and it is suggested that a copy of each accident form is taken after completion and filed on the relevant service user’s case record. The effective use of the accident records as monitoring tools was indicated by the individual risk assessment devised following one accident. This was good practice. DS0000011007.V294891.R02.S.doc Version 5.1 Page 30 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 DS0000011007.V294891.R02.S.doc Version 5.1 Page 31 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(2) Requirement The manager must ensure that service users care plans are reviewed in accordance with this Standard and Regulation 15. The provider must ensure that appropriate adaptations are made to the environment to meet the needs of service users with hearing and sight impairment and those who experience confusion. The manager must ensure that the identified bathrooms are decorated to an appropriate standard. The manager must ensure that the laundry building is brought up to an acceptable structural standard with regard to health and safety. The manager must ensure that staffing levels and deployment are sufficient at all times, to meet service users’ needs, and should review the current position to establish this. The manager must ensure that POVA training is provided to any staff who have not received this, DS0000011007.V294891.R02.S.doc Timescale for action 29/09/06 2 OP8 23(2)(a) &(n) 29/12/06 3 OP19 23(2)(d) 29/12/06 4 OP26 23(2)(b) 29/09/06 5 OP27 18(1)(a) 29/08/06 6 OP30 13(6) 29/08/06 Version 5.1 Page 32 7 OP33 24(2) 8 OP38 17(1)(a) & Schedule 3.3(j) and should establish a programme of periodical updates for this training for all staff. The provider must produce a summary report of the quality assurance review results and make it available to service users. The manager must ensure that records of accidents to service users are also provided within their individual case records. 29/09/06 29/08/06 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 Refer to Standard OP8 OP19 Good Practice Recommendations The manager should ensure that appropriate records of pressure sores are maintained in all cases. The provider should consider the provision of some sensory planting and raised beds, to provide sensory stimulation to service users and possible opportunities for limited gardening activities. The provider should ensure that the planned developments of the unit do not lead to a reduction of available communal space, in line with this standard. The manager should obtain the current home office guidance on overseas recruitment to ensure that the home fully complies with current legislation. The provider should produce an annual development plan for the home as defined in the Standard. 3 4 5 OP20 OP29 OP33 DS0000011007.V294891.R02.S.doc Version 5.1 Page 33 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 DS0000011007.V294891.R02.S.doc Version 5.1 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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