Inspection on 07/06/06 for The Mount

This inspection was carried out on 7th June 2006.

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

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

Other inspections for this house

The Mount 23/06/09

The Mount 30/06/08

The Mount 06/08/07

The Mount 27/11/06

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 Cathy Moore Unannounced Inspection 7th June 2006 07:45 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.V297797.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.V297797.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 01384 265955 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jenny Green Susan Foster Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Mount DS0000025043.V297797.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. 24 & 27 October 2005. Date of last inspection Brief Description of the Service: The Mount is a residential home registered to provide 24-hour care and support for 18 people over the age of 65 although only 16 were accommodated at the time of this inspection. The property is a large 2 storey detached house situated on Brettell Lane, Amblecote and is within easy access by public transport. The home has recently been extended to incorporate a previously detached bungalow. There are gardens to the front and rear and car parking facilities to the side of the house. There are 16 single and 1 double rooms with the majority having en-suite toilet and hand wash basin facilities. There is a small lounge area with attached conservatory within the dining area, a larger main lounge and a further small lounge in the bungalow extension. Access to the first floor is via a lift or main stairway. The laundry is located in the cellar and is not accessible to service users. There is one assisted bath located on the 1st floor a shower room and new walk-in shower on the ground floor. Fee range for The Mount is £343- £368 per week. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day between 07.55 and 18.45 hours, it was carried out by two inspectors and a pharmacy inspector. Three residents’ were case tracked this process involved assessing their care plans records and care. A total of nine residents’ were spoken to and three relatives. The premises were randomly assessed including the communal areas, kitchen, laundry, 4 bedrooms, bathrooms and toilets and gardens. Medication management, safety and administration were all assessed by the pharmacy inspector. Four staff were spoken to. Three staff files assessed for good practice concerning recruitment processes and training. Health and safety, maintenance and infection control measures were also assessed. Resident questionnaires were sent to the home for completion before the inspection to give more information as to the views of the residents’ living at the home. Six in total were returned all completed by residents’ who described themselves as being, ‘White British’. What the service does well: The manager and staff are motivated and eager to provide a good level of service to the residents’ in their care. The home promotes a friendly atmosphere and encourages residents’ to develop positive relationships with each other this evidenced by observation; residents’ knew each others name and a bit about each other. There was good conversation between the residents when they were sitting in both the lounge and dining room. It was extremely positive to see that on entering the home early in the morning, residents in the lounge who had got up early had been given a warm drink before their breakfast. The home actively encourages residents’ to maintain contacts with family and friends. Visiting times are open and flexible. Residents’ can bring into the home with them a range of their own personal belongings. The home has an ‘orientation’ board displayed in the main lounge, which details the date and the names of staff on duty throughout the day. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 6 The home has a good, well produced medication policy. It is very positive in that 6 of the 6 completed resident questionnaires received confirmed that they, ‘receive the medical support they need’. Over 50 of the care staff have attained N.V.Q level 2 or above in care. Positive comments were received from relatives and residents’ about the home and included the following; “ Very pleasant here”. “ Staff are very nice”. “ Manager is very nice always has a cheery word”. “ We are welcomed and given a cup of tea when we visit”. “ The home is lovely, he is well looked after”. “ Her bedroom is nice, it overlooks the garden”. What has improved since the last inspection? What they could do better: A number of major concerns were identified during this inspection in terms of infection control, health and safety and food hygiene. Problems highlighted were the lack of space and equipment/ cleanliness in the laundry. The lack of upkeep and cleaning in the kitchen. The laundry and kitchen were the worst ever seen by the two inspectors’ on site. A serious concern letter was issued by the Commission for the concerning issues seen to be addressed and resolved. Staff training needs to be on-going to ensure that gaps do not occur particularly in areas such as food hygiene and first aid. Staff recruitment is a worry at least two staff have been allowed to commence employment without the home firstly receiving a Criminal Records Bureau check for them. For one of these staff there was only one written reference instead of the required two. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 7 Care planning and health and personal care issues need improving to ensure that all residents’ receive the care that they need. Medication systems and management although improved in some areas require improvement in others to ensure safety. Activity provision needs to be improved in all aspects from providing staff hours to deliver activities to finding out what activities the residents want to do. Protection processes must be enhanced. Staff must all receive abuse awareness training. Staff must not be allowed to carry out non- care duties unless the care hours per week are increased. Their time must be spent caring. The homes’ environment needs to be improved especially the garden to get rid of the moss and weed build up. Quality monitoring processes need further development and more attention so that the manager can identify any concerns quickly and resolve these. Hot pipe work and radiators throughout the home (which have not already) must be suitably guarded to prevent risk of burning to the residents’. Insufficient staff at the moment have a valid first aid certificate. 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 DS0000025043.V297797.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.V297797.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The overall outcome for this group of standards is judged to be adequate. Prospective residents’ are given adequate information about the home prior to their admission, including an offer to visit the home. Contract/ terms and condition and assessment of need processes however, require further development. EVIDENCE: It is extremely positive that six of the six completed resident questionnaires received confirmed that they had all received enough information about the home before they moved in to enable a decision about whether it would be suitable for them. The service user guide and a copy of the homes’ last inspection report were on display within the home to inform residents’ further. Five of the six completed resident questionnaires confirmed that they had been issued with a contract or terms and conditions document. The fact that these documents are being issued was evidenced by case tracking processes. Documents seen were signed and dated by the resident or relative as they should be. Information contained within the documents however, does not The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 10 always clearly inform residents ’of their rights where the home state that they have no responsibility for certain areas. It is positive also that an assessment of need process and documentation is in place; however, some sections of the document either are not being completed or fully completed wherein important information is missed. It was pleasing also to see evidence to prove that the home is obtaining assessment documentation from prospective residents’ case managers from their funding authority. A small number of residents’ appear to have needs that fall outside of the categories detailed on the homes’ certificate of registration, although the manager is aware of this processes have not to date been completed to address this. Evidence was available to prove that prospective residents’ and or their relatives’ are invited to visit the home before admission. Confirming this, one relative said;” I came and had a look around before he came in”. The Mount DS0000025043.V297797.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. The overall outcome for this group of standards is judged to be adequate. Further developments and improvements are needed in relation to care planning, health care, medication and last wishes to ensure that these high risk areas of care are met. EVIDENCE: It is positive that a care plan was seen on file for each of the residents’ who were ‘case tracked’. Generally, the style and the layout of the care plans was good, in that they are clear and straightforward. A number of care plans need to be expanded further to ensure that all needs are fully captured examples being; pressure area care and equipment appliances in place and how to use these. Care plans for residents’ who are incontinent or visually impaired. Short term care plans were lacking as one is not being generated when for example; a resident becomes incontinent. It is extremely important to ensure that all staff are aware of what must be done for each resident that care plans are reviewed often or indeed when any changes occur. It was noted that not all care plans are being signed and dated by the residents’ or their chosen others to prove their involvement in the care planning process. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 12 Elements of personal and health care provision were concerning. For example one resident showed the inspectors’ her bruised arm and said; “ Have you ever seen anything like this?” There was no written explanation for the bruising, no bruise monitoring processes or prevention measures in place. Weight monitoring was another area that was lacking in terms of the required frequency for residents’ who had lost weight. Similarly, a number of residents are not being weighed at all. The manager confirmed that this was because they either could not or were not safe to use conventional stand on weighing scales. The home does not have any sit-on weighing scales. On entry to the home a strong odour was detected by both inspectors that was stronger by one resident who suffered from incontinence. There was insufficient evidence to prove that this person had, had sufficient personal care provided or if the doctor had been asked to rule out an infection. It was observed that this residents’ nails were not as clean as they should be. It is positive that good records are made of professional visits by doctors and other health care professionals. It is very positive in that 6 of the 6 completed resident questionnaires received confirmed that they, ‘receive the medical support they need’. 4 of the 6 resident questionnaires confirmed that they, ‘receive the care and support they need”, 2 felt that they, “usually did”. Positive comments were made by relatives during the inspection. One said, “there are no problems with his personal care. He is much better now”. The home has a comprehensive medication policy. Medication charts were seen to be clear and well documented. The storage of medication however, needs to be at the correct temperature. The temperature of the storage room was found to be over 30oc. Systems for checking that medication has been given to residents’ as prescribed by their doctors’ could be better improved for example; some residents medication was not always available to administer. It was evident from looking at records that staff are not determining for all residents’ their preferred form of address, religious and cultural needs or last wishes as they should. It was observed during the inspection that residents’ and staff have a very good relationship. Staff give choices to residents and talk to them with respect. Toilet and bathroom doors were seen to be shut when in use to enhance dignity and privacy. There was insufficient evidence to prove that the last wishes of residents are being explored and recorded for example; preferred funeral arrangements. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The overall outcome for this group of standards is judged to be adequate. Whilst the home actively encourages residents to maintain contact with family and friends further developments are needed to ensure that the lifestyle experienced by residents meets their needs this includes meal provision. EVIDENCE: On entering the home early it was observed that six residents’ were already up and dressed. When asked, three of the six residents’ confirmed that they liked to get up early. One said;” I like to get up at 6 o’clock”. Another said;” I like to get up early”. From observations it was clear that these residents’ have developed very good relationships. There was much conversation and humour being shared. Residents’ were very friendly with the newest person to live at the home. The home does provide activities in-house on an ad-hoc basis. Residents’ are being ‘let down’ somewhat as dedicated activity provision hours are not provided to ensure that their full recreational needs are met. This confirmed by feedback from 6 completed resident questionnaires where 4 of the 6 confirmed that activities only ‘Sometimes’ provided that they can participate in. 1 did state that they ‘always’ are, 1 chose not to comment. It must be said that the staff do try very hard to provide seasonal activities and parties for instance The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 14 Christmas and Halloween. A party had recently been held for one resident who celebrated her 90th birthday. One comment was received which suggested that residents’ do not get the option to go out of the home into the community very often. The home has a visiting policy this however, is not displayed within the home. It was evident however, from conversations that the home does encourage visitors and for residents’ to maintain contact with family and friends. One relative said; “ I visit everyday- the staff always make me a drink when I come. Two other relatives who were sitting outside in the garden in the sunshine with a resident said;” We visit a number of times each week at different times”. It was observed that these visitors had also been provided with refreshments. A resident said; “ I have visitors’ everyday”. Residents can bring into the home with them personal belongings from home. This was evidenced by observations during the tour of the premises. Literature informing residents and staff of external independent advocacy services was on display in the ground floor hall. It was extremely positive that on entering the home early in the morning residents in the lounge who had got up early had been given a warm drink before their breakfast. The dining room is attractive, tables nicely laid with table decorations and condiments. The choice of food at breakfast time was extremely positive a range of cereals was offered along with whatever hot options residents’ wanted. It was observed that one had egg on toast, one tomatoes on toast another mushrooms and toast. The main meal of the day consisted of braised steak or ploughman’s and fruit crumble. One resident commented; “ I really enjoyed that”. Another said;” I always leave a clean plate”!. Of the six completed resident questionnaires received three stated; ‘ that they ‘ Always’ like the meals at the home. Three ‘Usually’ did. Written menus were available these did not however detail 4 main meals per day. Greater attention must be paid to the records of food / fluid consumption every day particularly for those residents’ who have lost weight or are at risk of loosing weight. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The overall outcome for this group of standards is judged to be adequate. Processes in respect of both complaints and protection need to be further developed and improved. Due to these factors but taking into consideration that there have been no allegations of abuse or no known non-reporting of abuse this section is assessed as being ‘Adequate’. EVIDENCE: The complaints procedure has been produced in a written format only which may make it difficult to read or understand by residents’ with poor eyesight or confusion. There was no evidence to suggest that complaints procedures are discussed with the residents or that they are supplied with their own copy. Feedback from the six completed resident questionnaires received was relatively encouraging in that five of the six confirmed that they know how to make a complaint. Four confirmed that they knew who to speak to if they are not happy. Two confirmed that they; ‘ Usually’ did. No complaints about the service have been received by the Commission for some significant time. The homes’ complaints log has no complaints detailed since 2002. It is positive that Dudley Councils Protection procedures are available within the home. The home has its own in-house protection procedures however, these do not comply with Dudley Councils procedures which are the ones that should be followed if an allegation or incident occurs. Further, there is no quick reference flow chart for staff to follow if an incident occurs which could potentially cause a delay in reporting. Only 4 staff to date have received the required abuse awareness training. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,25,26. The overall outcome for this group of standards is judged to be poor. Although the home generally is comfortable, maintenance is needed in a number of areas, the garden requires attention and the upkeep and facilities provided in the laundry are very poor. There are health and safety concerns in respect of the lack of ventilation in the conservatory and a number of radiators still remain unguarded. EVIDENCE: The home itself was found to be comfortable and homely, with a friendly atmosphere. The home does not have regular dedicated handyperson hours. Hours are given from the owners second home. The home has outdoor space which is in need of a good tidy up as there are a lot of weeds and moss. Garden benches have seen better days in that the varnish has all worn off. The conservatory roof has not had any attention for sometime, it was seen to be green in colour. External windowsills were seen to be poor in terms of décor. The carpet in the bedroom adjacent to the laundry The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 17 door is in need of stretching as in its present state it could be a potential tripping hazard. A number of bedroom were seen which look comfortable and homely. One relative said;” Her bedroom is very nice”. Although audits have been undertaken of the bedrooms they are not complete in that residents’ have not signed to say that they are satisfied in what has been provided in their bedrooms. Further, it is not highlighted where individual bedrooms fall short of 10 square metres. It is positive that residents now have a lockable facility in their bedroom. Either a lockable cupboard or box. Concern was raised in that a number of radiators still have not been permanently guarded. Turning them off is not a satisfactory solution especially for winter months. The conservatory although a very attractive room is not provided with any ventilation. In warm whether it gets very hot in there. Ground floor carpets were seen to stained. As previously stated there was a strong offensive odour on the ground floor. The soap dispenser units in bathrooms and toilets were empty. Material towels and bar soap were seen in bathrooms which could harbour bacteria. No cleaning schedules were available to confirm that cleaning is carried out regularly. Other areas of the home looked reasonable in terms of cleanliness. This confirmed by residents’. five of the six completed questionnaires said that the home was ‘Always’ fresh and clean. The laundry was the worst the two inspectors had ever seen. Facilities in the laundry are poor. A bucket of soiled clothing was seen soaking in a bucket. There is a lack of infection control and cleaning processes in place. The laundry can only be described as dirty, unsuitable for the size of the home and a risk in terms of infection transmission. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The overall outcome for this group of standards is judged to be poor. A number of areas in this section needs further improvement. Examples being; Staffing levels in there present form are inadequate. Staff recruitment potentially placing residents’ at risk. EVIDENCE: The home provides three staff per shift during day time hours. However, these care hours are depleted in that they have to attend to cleaning, laundry, activity and some catering tasks. The manager was not able to provide evidence that she has assessed staff hours against numbers and dependency levels. Four resident questionnaires said that staff;” ‘Usually’ are available when they were needed. Two said ‘Always’. There were many positive comments received about the staff generally which included; “ The girls are as good as gold”. “ Nothing is too much trouble”. Observation of the staff during the inspection showed them to be kind and caring. It is positive that over 50 of the care staff have achieved N.V.Q level 2 or above in care. Staff recruitment is concerning in that staff are being allowed to commence employment without a full Criminal Records Bureau check being received. Further, one of these staff had been allowed to start work with only one written reference instead of the required two. The manager asked the handyperson to attend to a task in a residents’ bedroom. When asked if his file could be examined it was identified that there The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 19 is not one on site. Similarly, there was no Criminal Records Bureau disclosure document on site for the hairdresser. Not all files contained a staff photo or a health declaration which was a risk in terms of one staff member who had previously sustained an injury. Training in a range of subjects is being arranged. It is proposed that dementia training will be delivered in September 2006. The manager however, did not know what qualifications or experience the proposed trainer has to determine their competence. There was little evidence of in-house induction. New staff have yet to commence the required induction standards. Staff files did not contain an individual training plan. There was little evidence to prove that all staff are receiving at least three full paid training days. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The overall outcome for this group of standards is judged to be poor. Most elements in this section concerning quality assurance and staff supervision require further development and improvement. Health and safety and the state of the kitchen are extremely concerning and require urgent remedial action to prevent risk to residents. EVIDENCE: The manager has been approved by the Commission as a ‘fit person’ to run and manage the home. The manager has achieved the Registered Managers Award. It is pleasing that the manager has implemented a quality monitoring system across the National Minimum Standards for Older people. The process however, requires further development as in its present form it identifies nonconformances but does not have formulised systems in place for corrective The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 21 actions. It is positive that the home has used questionnaires to gain the views of residents and their families. Three district nurses have also contributed to this process. The home does not have in place yet an annual business plan or framework in which feedback and other processes can be inputted into to plan future developments and improvement. It was apparent from viewing records that the owners are not giving the manager set budgets for provisions such as food making it difficult to ascertain how much can be spent. Similarly, petty cash and activity budget allocation is very low limiting activities and spontaneous expenditure. The manager is not an appointee for any residents’ money. The only money looked after by the home is small amounts of cash held in safekeeping. This money was checked against records and balances. It is positive that records evidence that the manager audits all the safekeeping records regularly. It was noted however, that the hairdresser does not issue individual receipts for the residents’ which may make auditing complicated. Further receipts for expenditure are not numbered. Again hindering auditing processes. Evidence was available to show that most staff are receiving one to one supervision. These sessions however, are not occurring as frequently as they should- 6 times per year. Health and safety in terms of hot item is the kitchen were of great concern. The stainless steel boiler flue so hot that skin stuck to it when touched. A hot water urn was located next to this yet there were no risk assessment mechanisms in place or suitable lock on the door to prevent access to this high risk equipment. An Environmental Health inspection had highlighted that there was no evidence to suggest that the lift had been serviced to the required standard. Hoisting equipment at the present time is being serviced annually instead of the required bi-annual frequency. It is a concern that elements of the last 5 year fixed electrical wiring test were assessed as being ‘ unsatisfactory’ yet there was no official documentation to confirm that these ‘unsatisfactory’ areas have been remedied. The kitchen in terms of cleanliness and hygiene was the worst ever seen by the two inspectors carrying out the inspection. Cleaning schedules were either not being completed consistently or are being completed without the tasks being carried out to the required standard. Kitchen cupboards, the fridge, freezer and cooker were all dirty. The cooker and deep fat fryer having a significant build up of grease and grime. The cook on duty was in and out of the kitchen wearing ‘whites’ with no other protective clothing. Her ‘whites’ looked like a good wash would be beneficial. Food hygiene leaves a lot to be desired in that sausage rolls cooked that morning were left on a work top for tea that afternoon, it was a very hot day. Potatoes were stored on the floor. A cream gateaux stored under uncooked pork chops. Mandatory training was identified as being weak in some areas. For instance three staff files were checked none of which held a valid first aid certificate, one of whom was a senior. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 22 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 3 2 2 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 1 2 x x x x 2 2 1 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 2 2 2 2 1 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5(1b)c) 17(2Sch 4(8) Requirement The registered person and manager must ensure that the resident contracts/terms and conditions be reviewed. Where a third party top up is agreed a separate contact document must be used specifying who will pay this and the amount. The registered person and manager must ensure that all areas of the homes’ preinspection pro-forma is complete and signed and dated by the resident or their chosen representative. The registered person and manager must be able to produce documentation to evidence; That all prospective residents’ are offered a pre-admission visit to the home. The outcomes of each preadmission visit to the home. Timescale for action 07/07/06 2 OP3 14(1) 14(1(a14) 1(c) 07/07/06 3 OP3 14(1) 14(1(a)14 (1)c) 07/07/06 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 24 4 OP4 14(1) 14(1)(a) 5 OP7 15 A variation request must be made to the Commission for the individuals identified, along with evidence that their needs can be met. Timescale of 01/12/05 not met). Care plans must continue to be improved for all service users and reviewed monthly or when needed. They must cover all aspects of health and social care and include risk assessments with particular attention to the prevention of falls. (This is an outstanding requirement from 27 July 2002- Still not met June 2006). The registered person and manager must ensure that; Care plans are expanded to capture all needs and risks examples being; Pressure area care and pressure relieving equipment required and how to use it. Care for residents’ who are blind or visually impaired. Incontinence. 01/08/06 07/07/06 6 OP7 15(1) 07/07/06 7 OP7 15(1) 15(2)(a) (c) The registered person and manager must ensure that; Care plans are fully reviewed monthly. That any changing needs for example infection or the onset of incontinence are included in the care plans. 07/07/06 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 25 That residents’ and or their chosen representatives signed and date their care plan to prove that they have been involved in it’s planning and production. 8 OP8 12(1(a) 12(1(b) 12(4) The registered person and manager must ensure that all residents’ are weighed monthly or more frequently where there is a concern. The registered person and manager must ensure that the cause of any bruising to residents’ skin is investigated and that the reason(s) for documented. That body mapping/ bruise chart processes/ records are used to record any bruising. That the doctor is specifically asked to assess where a resident has a tendency to bruise. 07/07/06 9 OP8 12(1(a)b) 13(4)(6) 07/07/06 10 OP8 12(1)(a) 12(1)(b) The registered person and manager must ensure that the doctor is asked to assess whether or not the resident identified during the inspection has a urine infection. To chase the district nurses to provide a new pressure relieving mattress for the one that is thought to be faulty. 16/06/06 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 26 11 OP8 12(1a)b 13(4 23(2)n The registered person and manager must ensure that a suitable sit on weighing scale is purchased to allow weight monitoring for residents’ who can not stand/use conventional stand on weighing scales. 07/07/07 12 OP8 12(1)(a) 12(1)(b) 13(3) 13 OP8 12(1)(a) 14 OP9 13(2) The registered person and manager must prevent any offensive odour in the home by making sure that each residents’ continence and personal care needs are met. The registered person and manager must ensure that clear records are made daily to confirm personal care delivered to each resident. All medication must be dated when opened and not used beyond its prescribed date. (Timescale of 01/11/05 not met). 25/06/07 25/06/06 01/07/06 15 OP9 13(2) 16 OP9 13(2) The registered person and manager must ensure that new residents’ medication is ratified by their doctor to confirm for example; administration times and dosages. This information must be recorded on their care plan and updated when changes are prescribed. The registered person and manager must ensure that; DS0000025043.V297797.R01.S.doc 01/07/06 01/07/06 The Mount Version 5.2 Page 27 All medicines are stored within the correct temperature rangebelow 25oc for the majority that do not require refrigeration. That the fridge is maintained at the correct temperature at all times. 17 OP9 13(2) The registered manager must ensure that medicine audit can be completed. The date of opening all medicine containers recorded and that any balances are carried over to new medicine charts. The registered person and manager must ensure that controlled drug storage is provided to meet The Misuse of Drugs ( Safe Custody ) Requirements 1973. The registered person and manager must ensure that staff record the amount of medicine administered where the dose is variable e.g ‘One or two’. The registered person and manager must ensure that external preparations be stored separately from internal preparations. The registered person and manager must ensure that the receipt of all medication is accurately recorded and follows the homes’ medication policy. The registered person and manager must ensure that there is medication available for the needs of the residents’. The registered person and manager must ensure that; The religious needs of each resident are determined and recorded. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 28 01/07/06 18 OP9 13(2) 31/07/06 19 OP9 13(2) 01/07/06 20 OP9 13(2) 01/07/06 21 OP9 13(2) 01/07/06 22 OP9 13(2) 01/07/06 23 OP12 12(4)(a) (b) 01/07/06 The preferred form of address for each resident is determined and recorded. That staff complete records available to record final wishes and spiritual needs of each resident. 24 OP12 16(2)(m) (n) The registered person and manager must ensure; That the section in each residents file relating to previous hobbies/interests is completed. To seek opportunities for residents’ to access the local and wider community. 25 OP12 16(2)(n) (m) The registered person and manager must undertake a documented audit to establish residents’ preferred activity and leisure past time requirements. Following this an appropriate activities programme must be produced. The names of each resident to participate in any activity must be recorded. 26 OP12 16(2(n(m) The registered person must 18(1)(a) ensure that 15 hours dedicated activity time is made available each week. These hours must be able to be evidence at all times. A defined sum of money must be made available ( other than the wages of the activity person) each month. A proposal for this must be forwarded to the CSCI. The registered person and manager must display the DS0000025043.V297797.R01.S.doc 15/07/06 15/07/06 15/07/06 27 OP13 12(5)(a) 01/07/06 The Mount Version 5.2 Page 29 28 OP15 12(1)(a) 13(4) home’s visiting times/policy within the home. The registered person and manager must implement food/fluid intake charts for each resident where a need or risk has been identified. 20/06/06 29 OP15 12(4b) The registered person and 17(2)Sch4 manager must ensure that the (13) menus reflect four main meals per day; breakfast, lunch , tea and supper. That menus are produced in a format appropriate to the needs of all residents’ an example being pictorial. 01/07/06 30 OP16 12(4)(b) 22(2)(5) (6) The registered person must be able to evidence that a copy of the homes’ complaints procedure has been issued to each resident. Produce the complaints’ in a format appropriate to all residents’ for example pictorial. The registered person must ensure that all staff receive adequate abuse awareness training. 15/07/06 31 OP18 13(6) 01/09/06 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 30 32 OP18 13(6) The registered person and manager must; Revise the homes’ abuse procedures to ensure that they accord with those produced by Dudley MBC. Produce after revision of the above a flow chart complete with stages and contacts/ contact numbers in case an allegation or incident of abuse for staff to use for referral and reference. Be able to evidence at all times that all staff are fully conversant with protection policies and procedures. To include on all procedures the need to inform the CSCI in accordance with Regulation 37 any incidents’ that may occur. 01/07/06 33 OP19 23 Develop a programme of routine maintenance and renewal of the fabric and decoration of the individual rooms and exterior of the building. This must include updating the kitchen. Door wedges must not be used. These are outstanding requirements from 27th July 2002 still not met in June 2006. The registered person and manager must ensure that the following are addressed; 01/08/06 34 OP19 23(2)(b) 23(2)(d) 01/08/06 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 31 The garden front and back to be tidied up to remove dead leaves, moss and weeds. This to include footpaths. The hedges at the front of the home must be tidied to ensure that the homes name sign can be seen easily from a distance. The front of the home requires attention where there has been Ivy growth. The window sills particularly at the front of the home must be redecorated. Garden benches must be revarnished. The conservatory roof must be thoroughly cleaned. Easy chairs in lounges with threadbare arms must be replaced. The carpet in the bedroom adjacent to the laundry door must be stretched. Paintwork in corridors to be repainted. The damaged assisted bath located on the first floor must be replaced. 35 OP24 16(2)(c) The registered person and manager must ensure that residents’ or their chosen representatives sign and date to say that they are satisfied or otherwise with furniture and fixtures/fittings in their bedrooms. This includes making them DS0000025043.V297797.R01.S.doc 01/08/06 The Mount Version 5.2 Page 32 36 OP25 13(4) aware of any undersize rooms. The registered person and manager must ensure that the hot pipes in the ground floor shower room are suitably and safely guarded. A serious concern letter was issued in which this requirement was included. 09/06/06 37 OP25 13(4) 23(2)(p) 38 OP26 13(3) 13(4) 23 The registered person and manager must ensure that there is adequate mechanical ventilation provided in the conservatory. The washing machine must be moved to the new laundry room or the existing cellar improved to meet health and safety standards. This includes sluicing and separate hand washing facilities for staff and repairs made to the tiling and exposed brickwork. These are outstanding requirements from 27th July 2002. Still not met June 2006. A serious concern letter was issued to the registered owner in which this requirement was included. Implement a policy and procedure for the safe handling of laundry. 07/07/06 21/06/06 39 OP26 13(3) 23(2)(k) The registered person and manager must ensure that a washing machine is purchased which has the capability to meet both disinfectant and sluice standards. This new washing machine is correctly plumbed into the new laundry facility in the extension. DS0000025043.V297797.R01.S.doc 14/06/06 The Mount Version 5.2 Page 33 Documentary evidence to prove that this has CSCI by the timescale set. An immediate requirement followed by a serious concern letter were issued to this effect. The registered person and manager must ensure that a written proposal is submitted to the CSCI to address all concerns in the laundry as described in the serious concern letter ( section E) issued. To confirm that all issues have been fully resolved. A serious concern letter was issued in which this requirement was included. The registered person and manager must ensure that; Hand wash signs are displayed in all bathroom, toilets and other high risk areas. That bar soap is not used in communal areas- this to include the staff wash room. That ‘material’ towels are not used in any communal areasthis to include the staff wash room. That the piece of wood at the front of the shower (ground floor shower room) is replaced with a more suitable material. That communal items examples being; razors and sponges are not left in or used as communal items. These must be used for the individual only and be The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 34 40 OP25 13(3) 23(2)(k) 21/06/06 41 OP26 13(4) 15/07/06 returned to their room after use. 42 OP26 13(3) 13(4) 13(2)(c) The registered person must ensure that cleaning schedules for the whole home divided into area are produced and are put into operation examples being; toilets and bathrooms. The registered person and manager must ensure that liquid soap is available at all times in all bathrooms, toilets and other high risk areas. 01/07/06 43 OP26 13(3) 13(4) 20/06/06 44 OP26 13(3) 13(4) The registered person and manager must ensure that; All mops and buckets are clearly labelled per room and are stored in the room they are to be used in for example; kitchen mop and bucket-kitchen. Mop heads are cleaned to disinfectant standards daily and are changed at least monthly. Records must be maintained to demonstrate that this is being done. That mop heads are left to dry between use in an upright position. 20/06/06 45 OP26 13(3) 13(4) The registered person and manager must ensure that all corridor carpets are deep cleaned regularly and that records are maintained to show DS0000025043.V297797.R01.S.doc 20/06/06 The Mount Version 5.2 Page 35 46 OP27 18(1)(a) that this has been done and by whom. The registered person and manager must obtain the Department of Health staffing hours assessment tool and ensure that documentation is available every month to prove that this is being used to determine staffing hours/levels. The registered person and manager must ensure that there are at least three care staff per all waking hours. Care staff hours are not to be used for ( the 15 hours activity provision as previously mentioned) cleaning or catering purposes. 01/07/06 47 OP27 18(1)(a) 01/07/06 48 OP29 18,19 Ensure that all information contained in Schedule 2 of the Care Homes Regulations 2001 in relation to the fitness of staff employed is undertaken prior to commencement of employment. These are outstanding requirements from 27th July 2002. Still not fully met June 2006. 21/06/06 49 OP29 19(2) 50 OP29 13(6) The registered person and manager must ensure that a full enhanced Criminal Records Bureau check is undertaken and received before staff commence employment. If extreme circumstances arise where staff are needed to be employed by POVA-First then the CSCI must firstly be informed. The registered person and DS0000025043.V297797.R01.S.doc 25/06/06 01/07/06 Page 36 The Mount Version 5.2 19(2) manager must ensure that a full file ( containing all the information detailed throughout the whole of Regulation 19/Schedules 2 and 4) for the handyperson is held on site. The registered person and manager must retain on site a copy of the hairdressers full CRB and public liability insurance. All staff must complete a planned in-house induction in addition to the external programme used to cover general care and health and safety standards. These are outstanding requirements from 27th July 2002. Still not fully met June 2006. 01/08/06 51 OP29 17(20 19(2) 52 OP30 18,19 01/07/06 53 OP30 18(1)(c) (i)(ii) 54 OP33 21,24 The registered person and manager must be able to by certification and other documents prove that all staff have received three days paid training in any 12 month period. Review the quality assurance and monitoring system. Seeks views from service users, staff and other stakeholders. This is an outstanding requirement. These are outstanding requirements from 5th October 2004. Still not fully completed June 2006. The registered person and manager must ensure that measures are developed to address non-conformances to DS0000025043.V297797.R01.S.doc 01/11/06 01/09/06 55 OP30 24 01/08/06 The Mount Version 5.2 Page 37 56 OP33 24 policy and procedures/ outcomes of audits. The registered person and manager must develop an annual business plan for the home a copy of which must be forwarded to the CSCI. The registered person must provide the manager with sufficient money (set documented amounts) for; A weekly petty cash. Kitchen and food. Activities. A written proposal must be submitted to the CSCI . 01/09/06 57 OP34 25(1)(2) (3) 01/07/07 58 OP34 25(3)( c) 59 OP35 16(2)(l) The registered person and manager must provide the CSCI with the homes’ latest certified accounts. The registered person and manager must ensure that; The hairdresser issues individual receipts. That all receipts are dated and numbered for ease of auditing. 01/07/06 01/07/06 60 OP36 18 01/08/06 Staff must be provided with regular supervision (a minimum of six per year) that covers all aspects of practice, philosophy of care in the home and career development needs. This is an outstanding requirement. These are outstanding requirements from 27th July 2002. Still not met June 2006. The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 38 This includes the manager. 61 OP38 12,13 Provision of radiator covers or low surface temperature radiators throughout the home. Risk assessments need to be carried out on the building and on staff activities, service users and any visitors both inside and outside the home. This is an outstanding requirement from June 2003 –Still not met June 2003. If this requirement is not met within the timescale set this time the CSCI may consider further action. 07/08/06 62 OP37 17(2) Implement policies and procedures as required, signed and dated by the manager. Evidence must be available to demonstrate that staff have read and understood these. (Timescale of 01/02/06 not fully met). 01/08/06 63 OP38 13(3) 13(4) 16(2)(j) The registered person and manager must ensure that a written proposal is submitted to the CSCI to address all concerns/issues raised throughout section F of the Serious Concern letter dated 8 June 2006 in respect of the DS0000025043.V297797.R01.S.doc 21/06/06 The Mount Version 5.2 Page 39 kitchen. A serious concern letter was issued in which this requirement was included. 64 OP38 13(3) 13(4) Regulation 37 notices must be sent to the Commission for all notifiable incidents. A procedure must be implemented to ensure all the required food health and safety checks are completed daily including cleaning, stock rotation, & temperature checks. These are outstanding requirements from 5th October 2004. Still not fully met June 2006. Regulation 26 reports must be submitted by the proprietor on a monthly basis. 65 OP38 13(4) The registered person after consultation with West Midlands Fire Service to determine a safe and suitable lock or bolt to be installed on a fire door, install a lock or bolt on the kitchen door to prevent resident/ unauthorised access to the kitchen to eradicate /minimise the risk of burning. Written confirmation must provided to the CSCI by the timescale set to evidence that this requirement has been fully met. In the interim period and thereafter accurate and current risk assessments must be in place at all times to prevent the risk of burning to staff. 09/06/06 01/07/06 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 40 66 OP38 13(4) A serious concern letter was issued in which this requirement was included. The registered person and manager must ensure that the hot pipes in the ground floor shower room are suitably and safely guarded. A serious concern letter was issued in which this requirement was included. 09/06/06 67 OP38 13(4)(c) 18(1)(a) The registered person and manager must ensure that; The planned first aid training is brought forward. That at least one staff member suitably qualified in first aid is provided on each shift (day and night). Evidence that this has been done must be provided to the CSCIwith rotas detailing the first aider on each shift and a new training date must be submitted by the timescale set. A serious concern letter was issued in which this requirement was included. Ensure all training needs identified in the plan are met. Timescale of 01/02/06 not fully met). This to include all mandatory training. Moving and handling, fire training and drills, infection control, health and safety and food hygiene. 14/06/06 68 OP38 13(3)13(4 13(5) 23(4) 01/09/06 69 OP38 13(4) 18(1)(A) The registered person and manager must provide documentary evidence to the DS0000025043.V297797.R01.S.doc 01/07/06 The Mount Version 5.2 Page 41 70 OP38 13(3) 16(2J) 18(1a) CSCI of the planned ‘trainers’ qualifications and competence. The registered person and manager must ensure that no staff prepare or serve food unless they have a valid food hygiene certificate. 17/06/06 71 OP38 13(4) 23(2)(c) The registered person and manager must obtain certification to prove that the lift is LOLER compliant and that it is being serviced to these standards. A copy of this certificate must be provided to the CSCI. 01/07/06 72 OP38 13(4) 23(2)(c) 73 OP38 13(4) 23(40 The registered person and manager must ensure that all bath hoists and other hoisting equipment is fully serviced every six months. The registered person and manager must provide certified evidence to the CSCI to demonstrate that all work highlighted on the ‘unsatisfactory’ 5 year fixed electrical wiring test dated 2003 has been addressed. 01/10/06 01/07/06 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 42 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 OP2 Good Practice Recommendations The registered person should ensure that the resident contract/ terms and condition documents comply with the Office of Fair Trading guidance; ” Unfair Terms in Care Home Contracts”. oft@eclogistics.co.uk or www.oft.gov.uk The registered person and manager should ensure that for handwritten medication charts that two staff check the record against the original prescription and both sign and date the chart to confirm accuracy. 2 OP9 The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 43 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Mount DS0000025043.V297797.R01.S.doc Version 5.2 Page 44 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!