Inspection on 30/06/05 for The Mount

This inspection was carried out on 30th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mount 23/04/08

The Mount 13/04/07

The Mount 08/12/05

The Mount 05/10/04

The Mount 21/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 The Mount 29 Palmer Lane Barrow on Humber North Lincolnshire DN19 7BS Lead Inspector Janet Lamb Unannounced 30 June 2005 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Mount Address 29 Palmer Lane Barrow on Humber North Lincolnshire DN19 7BS 01469 532897 NA NA Prime Life Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sandra Diane Hubbard Care Home 17 Category(ies) of LD Learning Disability (17) registration, with number of places The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mrs Hubbard needs to develop her knowledge regarding legislation that is relevant to the service user group and the impact that this is likely to have on her day to day management of the home. 2. Mrs Hubbard needs to be clear about her responsibilities within the protection of vulnerable adults policies and procedures and the lead role of the Local Authority. Date of last inspection 05/10/04 Brief Description of the Service: The Mount in Barrow on Humber, owned by Prime Life Ltd, provides persoanl care for 17 adults with learning disability, in single rooms (except for one double), on two storeys. The house with two bungalows is set in its own grounds, and is not suitable for people with physical disabilities (though one bungalow is suitable). Local shops and amenities are close by in the village and the home has its own transport. There are large gardens for residents use. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over six hours and was one of the two inspections the home is required to have in each year. The Inspector looked around the house and talked to residents, the Manager and staff. Some of the records were inspected. Of the 15 residents living in the home four were interviewed and another two were briefly spoken to. The Inspector had tea with three residents as part of the interview. The Manager was supervising two care staff working in the home. Both care staff were interviewed. The Inspector observed interaction between residents and staff, and between residents. What the service does well: What has improved since the last inspection? What they could do better: The Manager could put details in writing to prospective residents whether or not the home can meet their needs. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 6 The Manager could further develop the systems for seeking residents’ views about the running of the home and their care, by seeking more regular responses and also seeking more input from relatives. The Manager could renew the systems for supervising staff to enable problems to be tackled quickly and efficiently. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 4. The information for prospective residents to choose whether or not to live in the home is still in need of reviewing to include all of the items listed in schedule 1 of the Care Homes for Younger Adults and Adult Placements, Care Homes Regulations. The service user guide has not been properly reviewed since long before the last inspection and needs updating to include the new buildings. EVIDENCE: The Manager uses community care assessment documentation as the basis for compiling plans of care for residents. If, when she and the staff observe residents and their needs prove to be differing, then plans of care are compiled from these newly identified needs. Community care documents and forms completed by the Manager are held in residents’ files. Staff spoken to confirmed the assessment and plan of care processes, as they too are involved in assessing and determining the needs of residents by using ‘person centred planning’ systems. Residents when asked about assessments found it difficult to fully understand but were clearly aware that staff maintain records and documents about their care. Residents are able to discuss the things that are important to them, the key people and staff in their lives, and gave a good account of what their needs are and how they are met. Information from the Manager shows prospective The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 9 residents can visit several times, have a meal, stay over and increase the length of stays before moving in permanently. One resident, in another of the company’s homes, is currently doing this with the view to moving to The Mount. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. Residents needs are reflected in individual plans of care. The staff team encourage self-determination but offer good support when needed, taking risks and risk assessments into consideration. We decided opportunities in the home to be consulted about everyday life are improving with the introduction of a quality assurance system. EVIDENCE: Plans of care are reviewed regularly and recorded so, and in them staff always try to reflect assessed and changing needs. There are risk assessments in place and staff confirmed their involvement in reviews of care and risk management strategies. Residents were observed having their social and emotional needs met and spoke at length of the things they find interesting and fulfilling. Residents asked questions of staff and seek support in their daily lives but also make final decisions. Risk taking is part of seeking independence and especially so for those in the bungalows, where they do many of their own domestic chores and attend community activities unaccompanied. Residents gave clear verbal and physical indications that they are given choices and make daily decisions. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 11 Residents have been getting more involved in residents’ meetings and many of them had input into choosing furniture and decorations etc. in the bungalows. Minutes of these meetings are available. One resident moved rooms into what used to be the laundry. The laundry is being relocated. She and her family made choices about how it would be furnished and decorated. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 and 17. There are good opportunities for residents to take part in activities within the local community and around, are encouraged to maintain relationships with families, friends and each other, and enjoy a satisfactory standard of food provision, although it was difficult to make a proper judgement about food, because residents had a take away fish and chip lunch on the day of the inspection. They made a choice to have this. EVIDENCE: The main evidence for this section of the report came from the residents themselves, talking about their daily routines, likes and aspirations. At least three of those in the main house on the day of inspection had a spontaneous day; went to the local shops and purchased items they liked for tea. Two more spent quiet time in one of the lounges listening to music and handling sensory items, and nearly all residents sat out in the garden with Prime Life Estates workers after lunch for a gossip and to enjoy the sun. Staff spoken to were very committed to encouraging residents to take up pastimes that are appropriate to their abilities and wishes. There were few The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 13 comments from residents about the food provision on the day of inspection, and everyone having lunch ate together and managed to concentrate fully on their meal. One resident felt that some of the meals were better than others and that the female staff tended to be the better cooks. She expressed her like for fish and felt she and the other residents had plenty of variety. Residents were confident about being given something else if they did not want or like the what was on offer. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. Residents receive good support from staff, according to their preferences and choices, and staff do a good job of meeting physical and emotional health needs, with assistance from good community health care systems. Those residents capable of doing so are given a good opportunity to retain and administer their own medication. EVIDENCE: Residents are given assistance with personal care needs in a manner, which suits them. Care needs and action to meet them are recorded in plans of care and diary notes. Residents have good relationships with staff that understand their preferences and choices. Daily diary notes show this. Those residents living in the bungalows retain, administer and control their own medicines and take care of their own valuables. One resident showed the Inspector where he keeps his medication, and explained how he administered it and recorded it in the diary notes he maintains himself. There are policies, procedures and risk assessment documents in place for those who self-medicate. Most residents receive medication form trained and accredited staff. Medicines are properly stored, administered and recorded according to policy and guidelines. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The Manager and the staff have made improvements in listening to and acting upon residents’ views. There is a reasonably good level of protection for residents, from abuse, neglect or self-harm, even though residents are not fully understanding of the complaint procedure. EVIDENCE: Residents were observed asking staff to help them and were seen to be making decisions about their daily lives. Staff were observed acting on choices and suggestions while trying to encourage independence. No resident made comments or acted in such a way to imply they were dissatisfied with anything. When asked about making complaints they said they did not have any but would talk to one of the staff. They did not seem to be fully aware of the complaint procedure or where it was. They were included in conversations and assisted with some of the chores in the kitchen and dining room. They generally seemed to be enjoying having visitors to entertain: Prime Life Estates workers were carrying out alterations to one of the lounges and the Inspector had arrived unexpectedly. The Manager has completed Protection of Vulnerable Adults training and staff have been covering this on the Learning Disability Award Framework programme they are registered for. Staff have also done some training, which includes intervening in situations where residents may be harming one another or staff, but which ensures there is no counter abuse or harm from the action taken. There are complaint, abuse, missing person and whistle blowing procedures in place, along with many more in the company policy manual, which are well understood by staff. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. At the present time the home is homely and comfortable, but that this is overshadowed by the alterations underway, and should be much improved once they are finished. The staff maintain a reasonably clean home considering the refurbishment is taking place. Residents living in the bungalows are not affected by all of this and do a good job of keeping their places clean, tidy and free from odours. EVIDENCE: A tour of the buildings with the Manager revealed the home is in different states and stages of refurbishment, redecoration and alteration. One lounge is being converted to a therapy room with Jacuzzi hot tub, changing room, shower and toilet. A ramp is being built to the side of the lounge to provide an access to the facility without having to go through the home. The facility will then be available to residents at The Mount as well as other residents in homes belonging to Prime Life Ltd. A bedroom has been relocated to the old laundry room on the ground floor, and a new laundry is being established. The Manager is to have a new office, bathrooms are being upgraded and bedrooms are being refurbished. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 17 Residents were aware of the changes and one or two made requests for bookshelves, wallpaper and paint colours and new furniture. The Inspector acknowledges that cleanliness in the home is compromised at the moment, but shall be restored to its usual standard once all works are completed. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 36. Residents are adequately protected by the home’s recruitment and selection procedures and practices. The systems for supervising staff are satisfactory, but require rejuvenating if they are to be effective in offering benefit to residents. EVIDENCE: Staff files were not seen, but discussion with the staff and the Manager revealed that the home seeks information on a job application form, takes copies of birth and marriage certificates, passport or driving licence if available, and takes two written references. All staff are checked with the Criminal Records Bureau before they begin work. The Manager maintains close supervision of staff on a daily basis and carries out formal supervision interviews, which are recorded. These should be revived somewhat, as staff said they had slipped a little. There is a complaint procedure for residents to use, which most of them are not fully aware of, and a whistle blowing policy and procedure in place for staff to utilise. Staff confirmed their training opportunities and courses they had done in interview. The Manager confirmed the home’s procedures for recruitment. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No judgement was made in this section because none of the outcomes for standards, key or otherwise, were considered. EVIDENCE: Not applicable at this inspection. The Mount J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Mount Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 and 5 Requirement The Registered Provider must review the homes statement of purpose to include all items in schedule 1. Missing one include 4, 7, 8, 9, 11, 14, 15 and 16. The Registered Provider must review the service users guide to meet the requirements of the regulation and to include the new buildings and the current refurbishments. It must also set out the physical environmental standards in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2. The Registered Provider must ensure staff receive training on infection control. Timescale for action 30/09/05 2. YA1 4 and 5 31/10/05 3. YA30 & 36 16(2)(j) & 18(1)c 30/11/05 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 YA32 Good Practice Recommendations The Registered Provider should ensure 50 of care staff achieve NVQ level 2 or 3 by the end of 2005. J54_s2815_The Mount_v229646_230605_Stage 4.doc Version 1.30 Page 22 The Mount Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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