Inspection on 06/08/07 for The Mount

This inspection was carried out on 6th August 2007.

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

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

Other inspections for this house

The Mount 23/06/09

The Mount 30/06/08

The Mount 27/11/06

The Mount 07/06/06

The Mount 24/10/05

The Mount 14/04/05

The Mount 05/10/04

The Mount 15/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Mount 226 Brettell Lane Amblecote Stourbridge West Midlands DY8 4BQ Lead Inspector Mrs Cathy Moore Key Unannounced Inspection 07:30 06th August 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Address 226 Brettell Lane Amblecote Stourbridge West Midlands DY8 4BQ 01384 265955 F/P01384 265955 shortysue@blueyonder.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jenny Green Susan Foster Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 21.11.05 may be accommodated at the home in the category DE(E). This will remain until such time that the service users placement is terminated. 27th November 2006 Date of last inspection Brief Description of the Service: The Mount is registered to provide 24-hour care and support for 18 people over the age of 65. It does not provide nursing care. The property is a large 2 storey detached house situated on Brettell Lane, Amblecote and is within easy access by public transport. The home has recently been extended to incorporate a previously detached bungalow. There are gardens to the front and rear and car parking facilities to the side of the house. There are 16 single and 1 double rooms with the majority having en-suite toilet and hand wash basin facilities. Shared space comprises of a dining room, lounge, conservatory. A smaller lounge is also available but this is not used very often. Access to the first floor is via a lift or main stairway. The home has an assisted bath located on the 1st floor a shower room and a walk-in shower on the ground floor. Fee range for The Mount is £353- £383 per week. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day by one inspector between 07.30 and 16.00 hours. Prior to the inspection a questionnaire was sent to the manager to complete to give us up-to-date information about the service. I carried out the inspection in communal areas where I could observe, daily routines, involvement between staff and service users’ and meal times. I spoke with two relatives, three staff and five service users’. The manager was involved in the inspection process. I randomly looked at the premises to include; the garden, living and dining room, the kitchen, laundry and four bedrooms. I looked at two service user files to assess assessment and care planning processes. I looked at three staff files to assess recruitment and training. I looked at medication systems to assess safety. I looked at health and safety and maintenance records to make sure that equipment and other systems within the home are safe. What the service does well: The home, due to its small size is able to offer a more personalised service. The manager and staff are motivated and keen to provide a good service to people in their care. The home provides a positive, friendly atmosphere. All but one new staff member has achieved NVQ level 2 or above in care which means that all of these staff have been assessed as being competent to carryout their job roles. The home has an open visiting policy. Service users’ are encouraged to maintain contact with family and friends. Medication systems are well managed and are safe. Positive comments were received about the home from people spoken to during the inspection which included; “ The home is lovely. I looked at one or two, this one was the best”. “ I like the people here”. “ It is small and homelylike a family. I really like it”. “ Very nice, very good”. “ No improvements needed. I like it here and I am happy”. A staff member told me; “ I know they are all cared for”. Another staff member said; “ Everyone is cared for”. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans need some further development to ensure that all needs such as those of medical conditions are all included. Care plans must be in place to show how infections are being managed to prevent spread. Risk assessments following falls must be updated and evaluated to prevent risk of injury. The carpet on the landing needs to be replaced and the floor boards beneath secured to prevent accidents. On-going redecoration and replacement of carpets is needed to enhance the home further. The kitchen needs more attention to ensure that it is clean and hygienic at all times. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4. Quality in this outcome area is good. No service user moves into the home without having had their needs assessed and being assured that these can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I saw that information such as; the last inspection report and service user guide were available in the home to help prospective service user’ decide if the home will be right for them. Service user’s I spoke to were positive about the home one told me; “ I have settled in and like it very much”. I looked at two service users’ files each had a signed and dated terms and conditions, which is good as this informs them of their rights. I did note however, the fee detailed on one of these documents referred to those of last financial year not this, which needs to be changed as this information is not correct . I saw written evidence to prove that an assessment of need had been carried out before service users’ were offered a placement. I also saw written The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 10 information provided by the funding authorities, which had been used during the assessment process for service users’. A completed form was held on one file which read; ‘ I have been offered a preadmission visit to The Mount. My family visited for me. I was given a copy of the service user guide and statement of purpose. A service user I spoke with who told me confirmed that pre-admission visits are offered; “ I have been here for about 8 months. I came and had a look around”. This evidence shows that the home encourages service users’ to visit the home, and that an assessment of need is carried out for each before they are offered a placement. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is good. Care plans require some further work to ensure that all relevant information and needs are included to keep service users’ safe. The personal and health care needs of service users’ overall are being met. Medication systems are well managed and are safe. Service users’ are treated with respect. Information concerning last wishes and arrangements are determined and recorded. Some information concerning this subject however, needs to be further explored in terms of capacity and legality. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I looked at two service users’ care plans and found that they were fairly comprehensive and detailed. What I did note however, was the lack of reference to past medical history examples being; angina and for one a current health problem in that she had an infection. Not including this information in care plans prevents staff having vital information on how to care for these individuals, which could place them at risk. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 12 I saw evidence to confirm that a range of risk assessments are carried out for each service user examples being; tissue viability and nutritional assessments. The home since the last inspection has obtained some ‘sit on scales’ to enable all service users’ to be weighed. I heard service users’ discussing their weights during lunch. One service user said; “ Its good, we don’t have to stand to be weighed we sit on a chair”. There was evidence on file to confirm access to health care services examples being; the doctor, district nurse and chiropodist. People I spoke to during the inspection further confirmed regular access to healthcare services as follows; “ I see the doctor and chiropodist. I’m going to have a hearing aid. They tried syringing but it did not work”. “ I see the doctor if I need to”. “ One of the doctors comes in every week as routine or they are called if needed. Very good the doctor’s practice is. I’ve known them come at ten o’clock when needed”. A relative told me; “ Oh if there is anything the doctor is called right away. The chiropodist was here two weeks ago”. During the inspection I took time to look at the service users’. I saw that they were all nicely presented. Ladies had their hair maintained, clothes that coordinated, some wore beads. Men were shaven. Nails and glasses looked clean. The teeth of one service user however, looked as though they needed a good clean. I raised this with the manager who told me; “ It is very difficult. She does not like anyone helping her with her teeth. We try. The dentist is coming next week so I am going to ask him for advice”. I looked at medication systems. I indirectly observed the senior in the morning giving medications. She did not rush. She asked service users’ if they wanted medications that were prescribed on an as needed basis such as painkillers and laxatives. She stayed with the service users’ until she was sure that they had taken their medication. Medication records all had a photograph of each service user to ensure correct identification. There were no staff initial gaps on medication records showing that staff ensure that records are maintained as they should be. I picked four staff names to check that they had received medication training. They all had a certificate to evidence that they received accredited medication training, which is good as this increases safety. I was pleased to see that special instructions were available for medication that needs to be administered differently from others’ such as Allendronic Acid. I was also pleased to see that staff confirmed each day the a prescribed supplement drink is being given as prescribed by initialling the medication record. I carried out five audits on different medications and was pleased to discover that tablet totals matched the amounts on medication records. The only shortfalls that I identified were that the temperature of the medication storage room is not being recorded and although all others were, controlled drug boxes were not being date labelled when the first tablet is used as they should for audit purposes. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 13 I observed staff during the day. They were polite and friendly to service users’ and visitors’. I saw that the preferred form of address is determined and recorded on admission and I heard that these were the names used by staff. I saw that toilet and bathroom doors were shut when in use to promote privacy and dignity. On each file I saw that it was recorded individuals choices concerning lat wishes and after death arrangements, which is good practice as if these wishes are known they can then be honoured. I was a bit concerned however, to see it recorded on service users’ files choice in terms of resuscitation either yes or no. I discussed this with the manager as in some instances it had been relatives who had made this decision not the service user. I explained about the implications of this in terms of consent and capacity. The situation further concerning as there was no evidence to suggest that a doctor, consultant or social worker had been involved in this decision making process. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. The lifestyle experienced by service users’ matches their expectations. Visiting times are open and flexible. Service users’ are encouraged to maintain contact with family and friends. Service users’ are encouraged to maintain control over their lives. Meals are varied and nutritious. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When I arrived at the home two service users’ were sitting in the lounge. They were both awake and alert, drinking tea. I asked them if they liked getting up at that time they told me they did. One said; “ I like to get up early. Always did at home. Once I am awake I don’t like to stay in bed”. During the morning I saw service users’ entering the dining room and coming into the lounge at different times. I heard a staff member saying to one service user; “ Good morning S you have had a lie in today haven’t you”? A staff member told me “ They can get up and go to bed when they want”. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 15 This evidence demonstrates that daily routines are flexible to meet the needs of the service users’. I saw that records to confirm activity provision have been kept since the last inspection. However, activity provision would be more variable and consistent if an activities co-ordinator was employed. It must be said that staff do try. I observed a music session in the afternoon, a number of service users’ joined in this and clearly enjoyed it. The manager told me that a singer comes to the home. The service users’ really enjoy this. The singer has made a CD so that the service users’ can enjoy the music in between the sessions. One service user told me; “ The staff do things with us and people come in”. Another said; “ On Sunday we went into the garden and sat under the umbrella. It was nice and hot”. I asked a service user if she had any religious needs. She told me; “ Yes, but not strict. On Sundays a staff member does a church service. We have all got hymnbooks and sing. We really look forward to that”. Visiting times in the home are open and flexible. I saw two visitors’ during the inspection. One told me; “ I visit everyday except Sundays. I am always made to feel welcome and am given a drink”. The other visitor confirmed, that he can visit at any time. All bedrooms I looked at held a range of service user belongings ranging from pictures, ornaments to televisions making the rooms feel homely and personalised. Two service users’ I spoke to spend most of their time in their rooms. They are fully alert and have capacity to make this decision. One told me; “ I go downstairs if there is something going on but other than that I like my own space”. The other told me; “ I like to spend my time in my room. The staff come and talk to me”. Both of these service users’ had good size televisions that they were watching. The dining room is homely and pleasant. I saw that the tables were nicely laid. The dining room has been provided with new lighting and new carpet, which look very nice. The home has a set menu, which has been produced in writing and part pictorial. These menus were available in the dining room to look at. Food detailed on the menus is interesting and varied. The meals for the day are also written on a board in the dining room. During breakfast and lunch- time I heard staff offering service users’ a choice. At breakfast time I saw that two service users’ had prunes. The cook told me; “One of the service users’ has fruit on her cereal”. The cook served the breakfast. It was very relaxed and there was a lot of chatting and conversation between the service users’. Lunch consisted of jacket potatoes with cheese and salad or gammon and parsley sauce, potatoes and peas. The meals were nicely presented and smelt very nice. Lemon or orange squash was available with the lunch. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 16 I asked staff and service users’ their views on the food provided and was given the following answers; “ The food is really nice. I’ve put on weight since being here. We have breakfast, lunch , tea and supper”. Another told me; “ I’ve put on weight since being here. I think it is the two puddings we are offered each day”! One person told me; “ The food is sometimes bland. Well, we had chicken for lunch the other day, then chicken sandwiches for tea”. “ They all enjoy their meals. They are all good eaters”. “ The food is good. The cook does some amazing food. The residents always comment how nice it is”. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. Complaints procedures are widely available in the home for service users’ and relatives to access if they have the need. Processes are in place to protect vulnerable people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been received by the home or by the Commission about the home, since before the last inspection. The home has a complaints procedure, which is detailed in the service user guide. A copy of the complaints procedure is also displayed in each bedroom. One service user told me; “ If I had a complaint I would go to the manager Sue”. One relative told me; “ I have no complaints. I do not find anything wrong at all”. Protection procedures are available within the home including those of Dudley MBC. Training records I saw confirmed that staff attend abuse awareness training, which was confirmed further by staff that I spoke to. As with all homes’ I inspect, on a one to one basis I asked service users’, relatives and staff if they had seen anything concerning in the home such as shouting, rough handling or hitting and was given the following answers; “ No abuse and nothing between residents”. “ Never, if there was anything I would report it immediately”. Oh, no nothing like that”. “ No nothing like that at all”. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,24,26. Quality in this outcome area is adequate. The home needs some redecoration and replacement of flooring. It is however, fairly spacious, comfortable and homely. Some development in terms of infection control is needed to prevent risk to service users’. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is reasonably decorated and furnished but does need some work doing. Since the last inspection a couple of bedrooms have been re-painted as has the dining room. One bedroom and the dining room have had new carpets. New lighting has been provided in the dining room. I discussed the upkeep of the home with the owner. I showed her one bedroom as an example and told her that the carpet and furniture should be replaced as they can only be described as ‘ shabby’. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 19 The flooring in the ground floor toilet has seen better days and would benefit from being replaced. Communal areas consist of a main lounge, conservatory and dining room. A small lounge is also available but is not used much. The home has a pleasant rear garden. I looked at four bedrooms. I saw that they were safe in that wardrobes are secure, window openings restricted and radiators guarded. They were comfortable and I did not detect any odour. Generally more effort could be made to enhancing bedrooms in that when they are repainted, it is only over existing wallpaper. Service users’ I spoke to however, are content with their bedrooms they told me; “ I like my bedroom”. “ I like my bedroom, my son has brought some things in from home”. A relative told me; “ His bedroom is lovely”. The laundry is small but located well away from any food preparation area. It has adequate machines for washing and drying. It is provided with two sinks to allow one for staff hand washing purposes as an infection control measure. Generally high-risk areas are provided with liquid soap, paper towels, gloves and hand wash signs. These were lacking however, in the first floor bathroom. One service user has MRSA. Although the district nurses are the ones at most risk as they have to renew dressings, protection within the home should be enhanced. There were no written guidance for staff to follow and although gloves , aprons and disposable bags were available in the bedroom these were white and yellow. I explained to the manager that red bags and aprons signify infection and these should be purchased and put in the bedroom for use to alert staff that these aprons and bags have been in an area open to infection and should not be used anywhere else. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. Service user needs are met by the numbers and skill mix of qualified staff . Recruitment processes are sound. The home has in place processes to properly induct new staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection the home had 3 empty beds. From observation and looking at records I felt that generally the dependency levels were lower than seen at previous inspections. The manager agreed with my assessment of this. Staffing is provided as follows; AM 1 senior and 2 carers. PM 1 senior and 2 carers. Nights 1 senior and 1 carer. A cook is provided every day and cleaner weekdays. The manager is also on site during business hours and other times when there is a need. All but one person I spoke to confirm that they felt staffing levels were adequate. This one felt that four staff, may be beneficial at times. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 21 I observed staff during the day. They were hard working, kind and friendly to the people in their care. Staff I spoke to clearly enjoyed their work they told me; “ I think it’s great here”. “ I really enjoy my job”. Service users’ told me; “ The staff are lovely”. “ All the staff are nice and kind”. All but one new staff member has achieved NVQ level 2 or above in care. Which means that all of these staff have been assessed as being competent to undertake their work. This is very impressive. I looked at two staff files to assess recruitment processes and found that these were sound. Two written references had been obtained and staff had been checked against the Protection Of Vulnerable Adults list and had a Criminal Records Bureau check carried out. A new cleaner is in the process of being employed. This will be the second cleaner to cover weekends and to double up with the existing cleaner once a week to enhance cleaning within the home. She has not started yet as the manager has not received official notification of her Criminal Records Bureau check. I saw that processes are in place to properly induct new staff to make sure that they are aware of what they should and should not do. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. The manager has been approved as a fit person to run and be in charge of the home. Processes are in place to ensure that the home is run in the best interests of the service users’ but require some further development. Service user money is safeguarded by the home. Some improvements are needed in terms of health and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission as a fit person to be in charge of the home has approved the manager. She has achieved her Registered Managers Award. This confirmed by a certificate dated 2005. The manager is very keen to carry on making any improvements needed within the home. She is pleasant and cares about the service users’. Two service The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 23 users’ told me about the manager; “ She’s great she is”. “ The manager Sue is very nice”. Staff told me that the manager supports them. One said; “ If anything we can go to Sue the manager. She is available 24 hours a day if we need her”. Another told me; “ I am really grateful to the manager. She gave me a great deal of help and support when I was doing my NVQ. Quality assurance processes are in place within the home. The manager in areas such as, medication carries out regular audits. Questionnaires are used to judge satisfaction with the service provided regarding the service users’ and relatives. Recent questionnaires have been used for visiting professionals such as doctors and nurses, which showed very positive feedback. To date analysis from questionnaires is not being displayed or published. The manager told me that she would address this. The owners visit the home regularly but do not always write a written report of their findings, as they should do. Money is held securely for service users who want their money secured by the home. I checked three service users’ money against records and balances and found that it was correct. I saw that two signatures verified each transaction; receipts were available as further confirmation of expenditure and evidence to confirm that the manager checks this money and the records regularly. From viewing staff files and speaking to staff I was able to determine that they have mostly all received all of the required mandatory training including as examples;1st aid, moving and handling and food hygiene which is positive as this increases safety in the home. I looked at certificates and records to make sure that equipment and appliances are being serviced as checked as they should and found that they were. Examples of which follow; emergency lighting checks May, June, July 2007. Fire alarm test done weekly, last checked 24.7.07. Oxford hoist service May 2007. Gas landlords safety certificate due to be attended to on 15 August 2007. In-house fire drills were carried out in May and June 2007. West Midlands Fire Service carried out an inspection in December 2006 and said; ‘ Satisfactory at this time’. I did note for one new lady that she had suffered two falls since admission during the night. Her history shows that she suffered falls before moving into the home. I discussed this with the manager and told her that I thought that risk assessments need to be reviewed and that consideration should be made to obtaining equipment to alert staff when she gets out of bed at night to prevent further falls. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 24 I noted that an area on the landing was a bit unsteady and could cause a tripping hazard. In places the joins in this carpet looked as though they were about to separate in two areas. I showed this to the manager and owner and told them that it needed attention as it could soon be a risk to service users’. I looked at the kitchen. The cook told me that the other cook was not at work at present and that she was covering this other person’s shifts. I saw that the cook has a valid food hygiene certificate. I did note that the kitchen looked dirtier than it should in places, which included plug sockets and tiles. The inner hinges of the microwave were covered with grease. The manager told me that she herself had cleaned the kitchen the week before but she would look into this. I saw that eggs were stored in the fridge. The cook told me that an Environmental Health Officer had told her that they must be. I told the cook that she should confirm this as I was concerned. That as these eggs were stored on the top shelf , that if broken they could contaminate food below. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 x x x 2 x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The registered person and manager must ensure that care plans are expanded to capture all needs and risks. Timescales of 07/07/06 and 05/12/06 not fully met. Example of this- Infection, past medical history conditions. 2 OP38 13(4)( c) The landing carpet must be replaced and the floor boards beneath made safe. This requirement has been made to prevent accidents and keep service users’ safe. Risk assessments must be evaluated whenever a service user has a fall. Consideration must be made to using equipment in the home such as monitoring devises to prevent accidents and falls. This requirement has been made to prevent accidents and to keep service users’ safe. The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 27 Timescale for action 20/09/07 20/09/07 3 OP38 13(4)( c) 10/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP9 OP11 OP16 OP19 Good Practice Recommendations Controlled drug packets should be date labelled when opened. Further exploration about decision-making concerning resuscitation is needed in terms of consent, capacity and legality. Complaints procedures should be produced in a format appropriate to all residents’ for example pictorial. Consideration should be made to enhance the general appearance of the home in terms of decoration and replacement of carpets, floorings and some bedroom furniture. Infection control processes should be in place examples being; Up to date guidance for staff on particular infections. Red disposable bags and aprons. The registered person should undertake at least monthly visits to the home and produce a report of their findings a copy of which must be given to the manager and be available for inspection. More attention must be paid or more hours allocated to ensure that the kitchen is adequately clean at all times. 5 OP26 6 OP33 7 OP38 The Mount DS0000025043.V341644.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Office Ground Floor, West Point Mucklow Office Park Halesowen B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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