CARE HOME ADULTS 18-65
The Mount And The Olives 9, 11 & 13 Delamark Road Sheerness Kent ME12 1RB Lead Inspector
Graham Cummings Announced Inspection 10th January 2006 09:30 The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 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 And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Mount And The Olives Address 9, 11 & 13 Delamark Road Sheerness Kent ME12 1RB 01795 665048 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) Isle of Sheppey Mencap Mr Kenneth Shaw Care Home 16 Category(ies) of Learning disability (16) registration, with number of places The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 1 Service User over the age of 64 whose date of birth is 23.08.1932. Date of last inspection 25th May 2005 Brief Description of the Service: The service offers 11 beds in the main house, The Mount, and 2 in the adjoining property, The Olives where service users are semi-independent. The main house has three floors, with bedrooms on the first, second and third floor. The adjoining property has three floors with bedrooms on the first and second floor. Both homes are located next door to each other in the centre of Sheerness within a short walking distance of all local amenities. The facility was first registered in 1977, having been built and supported by the local community, from where service users are admitted. Within the confines of the physical layout of the premises, some efforts have been made to comply with the environmental standards, largely by using former double rooms as singles when service users have left. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Graham Cummings and Mark Hemmings carried out the inspection on The 10th January 2006. The inspection consisted of speaking with 12 Residents, 2 staff, the Deputy Manager, Registered Manager and 3 parents, the Inspectors also looked at the completed Pre Inspection Questionnaire, 3 Relatives and 12 Resident comment cards, paperwork and toured both the main home The Mount and the semi-independent living home The Olives. On the information given to the Inspectors and the observations made it was clear that the Residents received a good quality of life and care, comments from the parents spoken to included ‘the staff are brilliant’ ‘as parents we know our son is happy and well cared for which gives us peace of mind’ and ‘the whole of The Mount and staff is a home to be proud of’. The staff spoken to were very knowledgeable about the care required to meet a specific individual residents needs and the daily records noted the different behaviours displayed. The Inspectors felt that the care plan/service user plans and other documentation did not do justice to the actual care and service provided and needed to improved. The Inspectors were concerned that the gas cooker in The Olives was very old and the grill and oven were not igniting when the ignition button was pushed and should be replaced following discussions with the 2 Residents and their families regarding whether to replace with a gas or electric cooker. The Inspectors agreed that the home has worked hard and made significant progress since the last inspection. The home is run in the best interests of the Residents and provided and good quality of care. What the service does well: What has improved since the last inspection?
The home has a continual maintenance program that has included new nets and curtains in The Olives. The Inspectors and Registered Manager and Deputy discussed the Requirements made at the last inspection and found that improvements had taken place: Requirement 1, the information of personal finances had improved but further improvements are required in the recording of monies held and handled by staff. Requirement 2: the Inspectors were informed that all the required paperwork was kept on the premises and was available for inspection. Requirement 3: This has been completed and written agreements were seen on Residents files seen. Requirement 4: This has been
The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 6 completed and window opening restrictors have been fitted where required. Requirement 5: This has been completed and the Inspector saw records of supervision that had been dated and signed by both participants. Requirement 6: The Inspectors were informed that Residents are given choices and options on a daily basis, the Inspector did not check that this had been completed. Requirement 7: The lift entrance/exit had been cleared and was easily accessible. The home has implemented some of the recommendations made at the last inspection, they are taking the temperature of the medication cupboard, all of the 4foot and 6 foot fluorescent lights have been fitted with diffusers and the second bed in the Residents room at The Olives has been repaired, the Resident had requested that it be left in the room as she liked to use it as a seating area. The home has made very good progress since the last inspection and is working hard to bring their paperwork up to the same level as the quality of care they provide. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Prospective users aspirations and needs are assessed. Residents have a written contract of terms and conditions with the home. EVIDENCE: The home carries out individual assessments prior to any placement starting, this involves the prospective Resident, care manager and family. The Residents individual files now contain a written contract setting out the terms and conditions of placement, the home does need to add the cost of the service and who the funding authority are. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 Residents care plans need to be updated. Residents make decisions about their lives with support. Residents are consulted and participate in all aspects of life in the home. EVIDENCE: The Inspectors looked at 2 care plans and found that the information contained in them was not as detailed or informative as the information that staff who were spoken to were aware of. The care provided by staff and the relationships they had with the Residents was extremely good but there was little of this written in the plan. The Residents are involved in decisions about their lives and had chosen to stay and speak to the Inspectors before going off to the Crawford Day Centre. Most of the Residents have been living at the home for over 10 years and have their own routines that are well known to the staff team. The Residents are encouraged to go into the local community with support and are encouraged to learn new skills. Residents are spoken to on an individual basis and at meal times rather than having formal Resident meetings, at present any comments made are being recorded. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,15 Residents have opportunities for personal development. Residents are part of the local community. Residents have appropriate personal family and sexual relationships. EVIDENCE: Residents attend the local day centre and participate in the daily activities. The home is within easy walking distance of Sheerness town centre and Residents frequently go shopping in the town and have some evenings in the local pubs. Over the Christmas period they had over 6 invites to community celebrations. Relationships between staff and Residents appeared as relaxed and friendly and family members spoken to were very complimentary about the relationships that staff had with their family member. The 2 Residents who live in The Olives help and support each other and share the chores and responsibilities of daily living without being a couple. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 Resident receive personal support in the way they prefer. Residents physical health needs are met. EVIDENCE: The Residents are able to participate in their personal support and care program and can indicate wishes and preferences. All of the Residents are registered with a local doctor, opticians and dentist and have their health needs met. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Residents views are listened to. Residents are protected from abuse. EVIDENCE: Residents finances are still not being recorded but there is nothing to suggest that any abuse is taking place, Inspectors have asked that each Resident has a form on their individual files that record the date, reason for expenditure amount in, amount spent and balance. It is essential that there is an audit trail of Residents finances that would help protect staff and management from possible accusations of financial abuse. Residents now have contracts on file that state that set amounts of money are deducted from individuals to pay for savings, activities and transport, these deductions need to be shown on the individuals new finance recording form. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Residents live in a homely, comfortable and safe environment. Residents bedrooms suit their needs. Residents bedrooms promote their independence. Residents have sufficient toilets and bathrooms and provide privacy. Shared spaces compliment Residents individual space. The home is clean and hygienic. EVIDENCE: Resident live in a safe, homely clean and hygienic environment. Residents have ample bathrooms and toilets that allows them privacy, their bedrooms were individualised and promoted independence, the rooms were furnished with individualised personal belongings and were comfortable and clean, the communal area were ample and would allow Residents to access quieter areas if they wished to do so. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36 Residents benefit from staff clarity of roles. Residents are supported by a competent staff team. Residents benefit from well supported and supervised staff. EVIDENCE: The Inspector spoke to 2 staff who were very knowledgeable on the care required for individual residents although the actual written care plans were lacking in some of the information staff were aware of. Staff spoken to were aware of their roles and responsibilities and procedures to follow if they had any concerns about any individual or their care. Staff are able to attend training courses, recent training has included Food Hygiene, National Pharmacy Association, Manual Handling, N.V.Q 2’s and First Aid. The Deputy has now completed her NVQ 4 and Registered Managers Award. It is planned that another 6 staff will be attending a First Aid course in the near future to update their certificates. Staff have regular individual supervision and the Inspector saw evidence of this and noted that the recording was signed by both persons involved. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42,43 Residents benefit from a well run home. Views of Residents are being recorded. Policies and Procedures are in place to protect the Residents. The homes record keeping needs to be improved. The Residents health, safety and welfare are promoted and protected. The management of the home is under review. EVIDENCE: The home is run to benefit the Residents, the care they receive is very good but the recording of the care required and given is in need of improving. The views of residents are listened too, recorded and acted upon. The homes policies and procedures are in place and available to staff at all times. The Residents health, safety and welfare is promoted and protected by the management and staff, there is an ongoing maintenance program to maintain the good standard of the property. The Management of the home is under review with the current Registered Manager looking to step down and the Deputy Manager apply for the Managers post now that they have been successful in achieving the NVQ 4 and RMA. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 3 2 3 3 The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA6 YA8 Regulation 15(2)(b) 24(3) Requirement Timescale for action 3. YA41 17 The registered person shall – keep the Service User plan under 31/03/06 review. The Registered person shall establish and maintain a system 31/03/06 for providing consultation with Service Users and the recording of this. The Registered person shall maintain in respect of each Service User a record which 01/05/06 includes the information documents and other records specified in Schedule 3 relating to the Service User. The Registered person should also ensure that these are evaluated and kept up to date. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 18 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 YA23 Good Practice Recommendations The Registered person implements a method of recording individual finance transactions from monies handled by staff from Residents personal money. The Mount And The Olives DS0000024026.V265236.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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