Inspection on 04/10/05 for The Mount

This inspection was carried out on 4th October 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mount 10/11/09

The Mount 05/12/08

The Mount 17/04/07

The Mount 05/07/06

The Mount 15/12/05

The Mount 16/11/04

The Mount 22/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Mount Wood Lane Yoxall Staffordshire DE13 8PH Lead Inspector Lorraine Mavengere Unannounced Inspection 4 October 2005 10:00 The Mount DS0000028634.V255850.R01.S.doc Version 5.0 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 DS0000028634.V255850.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Mount Address Wood Lane Yoxall Staffordshire DE13 8PH 01543 472081 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) Mr Graham Howard Cork John Mattew Wade Care Home 5 Category(ies) of Learning disability (5) registration, with number of places The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 5 LD aged 18 - 30 years on admission. Admission of 1 named individual under 18 years on admission Admission of 1 named individual over 30 years on admission Date of last inspection 16th November 2004 Brief Description of the Service: The Mount provides care for five adults with a mild learning disability and challenging behaviour. The home can cater for individuals ranging from 18 to 65 as per assessed need and suitability of placement. The property is a large detached modern house set in extensive grounds in a rural setting close to the small village of Yoxall, near to the town of Burton-onTrent and the city of Lichfield. Service users are admitted on the basis of education and rehabilitation planned towards either independent or semi-independent living. The home provides relevant staffing levels to meet individual needs. Residents are encouraged to fully participate in the daily running of the home, hold their own food budget, to assist in the preparation of meals and housekeeping tasks. The service users are encouraged to choose their own college courses and are supported by staff to access the college. The property is situated close to the local Post Office and shop and is on a main bus route for Burton-On-Trent and Lichfield. The proprietor provides mini bus transport. All residents have their own personal bedrooms and a wide range of leisure activities on site, such as horse riding, swimming, snooker, music and gardening. The home has access to specialist health services such as Psychiatrist/Psychologist and specialist nurses for learning disabilities subject to an appropriate referrals procedure. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Tuesday morning and afternoon through to the early evening. At the time of inspection, all five residents were on site. Four of the residents are very independent and can articulate their thoughts and feelings reasonably well. One has a little more difficulty but the staff facilitate for better communication in as much as possible. Of the five service users, the manager managed to speak to four of them, three of them in great detail. Their comments and contributions are included in this inspection report. There were three members of staff on each of the two shifts that the inspection covered. The staff on duty were spoken to on an informal basis, their comments too are included in the report. At present, the home has made an application for change of registration to increase the numbers from five to six, and also to add a category for one service user with mental health difficulties to be permitted to reside at The Mount. At the time of inspection, the room was not ready. A separate site visit has been arranged for the 24th of October 2005. What the service does well: What has improved since the last inspection? The statutory requirements from the last inspection have since been met. The service user guide that was not accessible to service users has now been put into formats that are suitable for the service user group. The home is using an organisation called Communicate who specializes in developing communication skills in order to further facilitate accessibility of all relevant information. Communicate is run by qualified speech and language therapists who are working to facilitate for better communication of information for service users with learning disabilities. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 6 All contracts are now signed and dated. This standard in now in full compliance with the national minimum standards and Care Homes Regulations 2001. The filing cabinet that had broken lock during the last inspection has been replaced and records are now secure and in line with the data protection 1998. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection The Mount DS0000028634.V255850.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, 3, 4, 5 Service Users are provided with clear information about the home to enable them to make an informed choice about whether they wish to live there. Prospective service users are only admitted into the home on the basis of a full assessment of needs. The assessments are lacking in some areas. The standard therefore was met with some shortfalls. Prospective service users know that their home will meet their needs. The home exercises a policy of introductory visits for all prospective service users. Both the home and the service user or their representative, are therefore able to ascertain the suitability of the placement. All service users have both a social services contract as well as the home’s own contract. The contract covers all areas highlighted in the standards. This gives clarity to all parties concerned as to the terms under which each service user is admitted. EVIDENCE: The statement of purpose was seen during the inspection. The information complies with the regulations and the national minimum standards. There was evidence that the service user guide was being worked on by an organisation called Communicate to improve accessibility for the service user group. Communicate specializes in putting information into formats that are suitable The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 9 for people with varying degrees of learning disabilities and is run by qualified speech therapists. It was quite evident that all service users have a pre admission assessment prior to moving into the home. As well as the home’s own pre admission process, the home is in receipt of the social worker’s community care assessments. The social worker’s assessment covers all areas specified in standard 2.3. It is strongly recommended that the home’s pre admission documents are developed to cover all stated areas. It was also noted during the inspection that the letterhead for the pre admission documents was that of another home within the same organisation. The registered manager must ensure that the home’s own pre admission documentation is used for the purposes of assessing a prospective service user for The Mount. There are no stated restrictions imposed on the current residents of The Mount. The statement of purpose very clearly states who the service is for. The statement of purpose and the training schedule together show that staff skills, experience and training is adequate to meet the needs of the service users at the home. Observed practice demonstrated that staff can communicate adequately with existing service users and use their preferred means of communication. Discussions with the registered manager confirmed that a placement would under no circumstances be offered unless the home was confident that they could meet the prospective service users’ needs. The Manager confirmed that any new service users would have the opportunity to have a look round and meet other service users. This is normally followed by an overnight stay or weekend stay. The type and amount of transition time would be based on the service users preferences and assessed needs. The home has a Trial Period policy in place this was seen during the inspection. Records seen show that a service user who had been recently admitted into the home did go through a successful trial period- the trial period was in line with the home’s policy. Records show that service users have a copy of their contract in their care files. The contracts seen were signed and contained all the relevant information stated in standard 5.2. The registered manager confirmed that Communicate will be working to getting the contracts, as well as all other service user information, into formats that are suitable for the service user group. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 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 the following standard(s): 6, 7, 8, 9, 10 The home has a formulated service user plan that describes the services and facilities offered to each individual service user in relation to their assessed needs. This ensures that all areas of care are met. Service users are assisted in making decisions about everyday matters with no restrictions except those assessed as a high risk. Service users actively participate in all aspects of life in the home and contribute to the development of services. Each area of assessed need is accompanied by a risk assessment but not all areas of risk have been assessed. Service user information is handles appropriately and is kept in a secure and confidential manner. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 11 EVIDENCE: Some care files were examined during the inspection. It was evident that all service users have a comprehensive placement plan in place that identifies all their care needs and gives clear instruction on how these are to be met. There was also evidence that the placement plans are reviewed regularly. Discussions with the registered manager highlighted that all service users have an allocated key worker who meets with the service user regularly to discuss issues of care. The service users spoken to on the day stated that they are actively involved in the placement planning and were very aware of their current goals and timescales for meeting these. The service users were spoken to at great length during the inspection. They were all able to confirm that their right to make decisions was respected at all times. This was evident in matters such as the decorating of individual bedrooms where service users had chosen their own colour scheme to reflect personal taste and preference. The service users were also able to confirm that they can and do participate in various community activities when they choose. Observed practice showed that staff provide service users with information that will help them make informed choices about their lives. Service users spoken to stated that they are consulted on, and participate in, all aspects of life in the home. When asked, service users said that they have regular meetings in which they discuss various issues to do with the running of the home. These include things such as the menu planning or if there are any changes to be made in the home. The registered manager confirmed that the home provides service users with comprehensive, accessible, understandable and up to date information about its policies, procedures, activities and services. Records showed that there were some risk assessments in place but not all areas of risk had been assessed. Risk assessments, including assessments on activities undertaken, are detailed in service user care plans. The home has a missing persons policy with each service user having information including communication needs in their care plans. The registered manager must ensure that all areas of identified risk are assessed fully and managed accordingly. The home has a comprehensive policy on confidentiality that was seen during the inspection, the home’s current practices are in line with this. All confidential records are stored and maintained in accordance with the Data Protection Act 1998. Service users are given information within their service users guide about the home’s policy on confidentiality. The registered manager confirmed that this is also explained verbally to them. The home also has an Access to Records policy. It is stated within this policy that service users have the right to access any information held by the home about them. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 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 the following standard(s): Standards not assessed on this occasion. These standards were assessed and fully met during the last inspection. EVIDENCE: The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19 Service users have access to all primary healthcare facilities as well as any specialist services as required. All health needs are therefore adequately catered for. EVIDENCE: Records show that all service users are registered with a General Practitioner and have access to all primary health care facilities such as the optician, dentist, and chiropodist as needed. The senior member of staff confirmed that where needed, referrals would be made for specialist services to meet identified needs. All physical and emotional health care needs are identified in the care plan with instruction on how to met these needs detailed alongside. On the day of inspection, none of the service users had pressure sores and there had been no admissions into Accidents and Emergencies since the last inspection. It was noted from one of the care files that one of the residents has on going support from psychology services to help deal with some identified difficult emotional needs. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 22 Service users are provided with clear information on how to make a complaint with contact details of other relevant agencies should they wish to use these. As a result, service users are certain that their grievances will be dealt with in a timely fashion. EVIDENCE: The home has a comprehensive policy and procedure on Complaints. The complaints log was seen. This showed that no complaints have been made since the last inspection. The manager stated that some of the residents at the home do make informal complaints that are usually resolved at that stage. As a result, the home is in the process of introducing a ‘grumbles’ book where all informal complaints can be recorded and action taken detailed. The Commission for Social Care Inspection has not received any letters or phone calls of complaint about the home. All service users spoken to stated that they knew how to complain and felt that their grievances would be resolved fairly and promptly. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 25, 26, 28 Service users bedrooms have useable floor space sufficient to meet individual needs and lifestyles. Service users’ bedrooms have furniture and fittings that are sufficient and suitable to meet individual needs and lifestyles. All communal areas are satisfactory in size allowing the service users un crowded living space. EVIDENCE: Although room sizes were not measured on this occasion, the registered manager confirmed that these have not been altered since they were first registered. In light of this, the rooms are the required size to meet service users’ needs. The home has applied to the commission to register an extra room. Room measurements of the proposed room were taken during the inspection and were as required by the standards. The proposed room has an en suite. The service users’ bedrooms were all individually decorated to suit each service users’ personal taste. Service users spoken to stated that they had chosen their own colour scheme for their bedrooms. This was very evident when The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 16 service users were talking about the work that they had done in their rooms. One resident in particular had put in a lot of work into achieving a very unique look for his bedroom and took great pride in it. Both the manager and the residents confirmed that all service users chose the items that go into their rooms. The national minimum for bedroom furnishing was met in accordance to residents’ assessed needs. The shared spaces are a good size and meet the standards for room sizes. Measurements were not taken on this occasion; measurements were based on those taken in previous inspections. All other aspects of the living shared areas, including the furnishings, were modern, comfortable and domestic in nature. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 Staffing levels are appropriate for current service user needs and the staff team collectively, and individually have the skills mix to meet needs. EVIDENCE: Observed practice on the day of inspection showed that staff know and support the aims and objectives of the home as outlined in the statement of purpose. Records showed that all new members of staff get a comprehensive induction programme that covers all aspects of the home, policies and procedures and care provision. Discussions with the registered manager confirmed that all members of staff are provided with a job description and a statement of terms and conditions for the work they do in the home. Records seen indicated that eight members of staff are trained to NVQ level 2 or above. The statement of purpose, training schedule and discussions with the members of staff themselves, demonstrate that the team has the skills and experience necessary for the tasks they are expected to do. Observations showed staff to be approachable, good communicators, interested, motivated and committed. It is recommended that 50 of the staff team be trained to NVQ level two or above to meet the Sector Skills Council workforce strategy targets. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 18 Rotas inspected show that there are 12 care staff and no staffing vacancies. The home operates on three members of staff during the morning shift, three members of staff during the afternoon shift and one waking night staff and one sleep in. As highlighted in the statement of purpose, the staff team have a mixture of skills and experience that enable them to meet service user needs. Staff spoken to were also able to confirm that they can attend various training courses to increase their competencies and as a rule are expected to attend mandatory training The Mount DS0000028634.V255850.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41, 43 The registered manager is qualified, competent and experienced to run the home. The management of the home creates an open, positive and inclusive atmosphere. Record keeping policies within the home are in line with statutory requirements enabling service users’ best interests to be safe guarded. Service users benefit from competent and accountable management of service. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 20 EVIDENCE: manager confirmed that he has five years management experience and holds an NVQ 4 in care management. All staff spoken to stated that they had faith in his management abilities and felt confident in his leadership skills. The atmosphere on the day of inspection was relaxed and cheerful. Staff spoken to all expressed their confidence in the registered manager and their leaders. Staff spoken to also confirmed that they understood and were comfortable with their lines of accountability. The processes of running the home appeared to be open and transparent. A thorough examination of documentation showed that records required by regulation for protection of service users and for the effective and efficient running of the home are maintained, up to date and accurate. There was no evidence however, that service users are informed of their right to access their personal records. It is recommended that the manager inform service users of their right to access information held by the home about them. The home’s business plan was not seen during the inspection. The employees’ liability insurance is displayed on the wall in the home’s main office, this expires in June 2006. The Mount DS0000028634.V255850.R01.S.doc Version 5.0 Page 21 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 3 2 3 3 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 3 X 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Mount Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 3 X 3 DS0000028634.V255850.R01.S.doc Version 5.0 Page 22 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 YA2 Regulation 14(1) Requirement The registered manager must ensure that the home’s own pre admission documentation is used for the purposes of assessing a prospective service user for The Mount. Timescale for action 31/10/05 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 YA2 Good Practice Recommendations It is strongly recommended that the home’s pre admission documents are developed to cover all stated areas. 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