Inspection on 10/07/06 for The Mount And The Olives

This inspection was carried out on 10th July 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mount And The Olives 10/01/06

The Mount And The Olives 25/05/05

The Mount And The Olives 09/07/04

The Mount And The Olives 17/03/04

Similar services:

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Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 The Mount And The Olives 9, 11 & 13 Delamark Road Sheerness Kent ME12 1RB Lead Inspector Graham Cummings Unannounced Inspection 10th July 2006 09:45 The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 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.V296314.R02.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 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.V296314.R02.S.doc Version 5.2 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 Mr Kenneth Barnard Shaw Care Home 16 Category(ies) of Learning disability (16) registration, with number of places The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 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 10th January 2006 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 fees range from £335 to £350 per week. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Graham Cummings carried out the unannounced site visit as the final part of the Key Inspection on the 7th July 2006. Prior to the site visit the Inspector had completed the Inspection Record and received the Pre Inspection Questionnaire and 8 Service User survey forms from the home. The Inspector went through the Inspecting for Better Lives 2 process with the Manager and Deputy of the home and answered any queries raised. The site visit consisted of a short tour of the home, speaking informally to 3 Service Users and staff with longer formal discussions with the Manager and Deputy, the Inspector also viewed documentation. The home has addressed the 3 Requirements made at the last inspection in January 2006 and is continuing to make improvements in the documentation and recording of information. The home has also purchased a new gas cooker for The Olives. The Service Users survey forms indicated that they were extremely happy and content with their lives at The Mount and Olives with quotes including ‘I like all the staff’ ‘I want to stay here’ ‘the staff are very kind to me’ ‘if I was not happy I would speak to the staff’ ‘it is brilliant’. Comments from staff were positive about the management and running of the home and there appeared to be a good working relationship and rapport between staff and management. No families were spoken to during this site visit but at the last inspection family members spoke very highly of the care and dedication of the staff. The lifestyle and outcomes for the Service Users is very good, the documentation and recording is now starting to reflect the hard work and good standard of care that has always been provided. What the service does well: The home is run in the best interests of the Service Users and outcomes for Service Users is positive. This was evidenced through conversations with the Service Users and the completed Service User survey forms. The home was welcoming and the atmosphere was relaxed and homely. The Residents are given a choice of activities and are an accepted part of the local community with regular outings for pub lunches, BBQ’s, discos and swimming. Since the last inspection Service Users have been to the Buddy Holly show and there are plans to visit the Kent County Show at the weekend. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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.V296314.R02.S.doc Version 5.2 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.V296314.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 The quality of the service is good. Prospective Service users have the information required to make an informed choice. 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 contain a written contract setting out the terms and conditions of placement; these have now been updated to include the cost of the service and who the purchasing authority are. The majority of the Service Users have been living at the home for between 20 and 30 years and are well known, accepted and part of the local community. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 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): 6,7,8,9, The quality of the service provided is good Individual care plans reflect Service users changing needs. Service Users make decisions about their lives with support of their family and staff. Service Users are consulted and participate in all aspects of life in the home. EVIDENCE: The care plans seen have been reviewed and are now written to reflect the needs of the individual concerned. The home now needs to ensure that these are evaluated regularly; if changes are made to reflect the changing need of the individual then they must be signed and dated. Service Users are involved in the running of the home and are consulted by the deputy manager on a regular basis individually or in small groups. The deputy has a small notebook that she writes down individual’s comments and wishes, these were seen and were signed and dated and acted upon. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 10 Service Users are encouraged to make their own decisions; this is usually through informed choice that ensures the safety and protection of the individual. Staff and family members work together wherever possible to provide a consistent care program. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 11 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): 11,12,13,14,15,16,17 The quality of the service provided is good. Service Users have opportunity for personal development. Service Uses are part of the local community and take part in appropriate leisure activities. Service Users have appropriate family relationships and support and their rights are respected. Service Users receive a nutritious and wholesome diet. EVIDENCE: The majority of the Service Users have been living at the home for between 20 and 30 years and are very well known in the community. They attend the local functions held by the Round Table including the weekly disco, attending the Crawford Day Centre, local College, BBQ’s and pub lunches. Service Users have recently attended the Buddy Holly Story show that was well appreciated by them. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 12 The Service User survey forms all comment that the food is good and they give their favourite food, on looking at the menu supplied with the Pre Inspection Questionnaire all of the mentioned foods were included. Staff cook meals and encourage Service Users to assist them in the preparation, the menu seen provided a wholesome and nutritious diet. On the day of the Inspection 8 of the Residents had chosen to attend the Crawford Day Centre and 1 was at college attending a Basic Skills course. 3 Residents remained at The Mount and 2 at The Olives. The 2 Residents who live at The Olives are semi independent and do their own shopping, cooking and are responsible for keeping the house clean and tidy. The Inspector noted that the Service Users who were in both houses had a good rapport with staff and Managers. Family members can visit the home at any time and are fully encouraged to participate in the individual’s day-to-day living. The 2 Service Users that live in The Olives went on holiday to Eastbourne with the Mother of one of them. This went very well and the holiday was thoroughly enjoyed. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 The quality of the service is good. Service Users receive personal support in the way they prefer. Service Users physical and emotional health needs are met and their wishes regarding illness and death are recorded. EVIDENCE: The Residents are able to participate in their personal support and care programme and can indicate their wishes and preferences. Service User families wherever possible are fully involved in this process. All of the Residents are registered with a local doctor, opticians and dentist and have their health needs met. Service users do not self medicate, should this change, the home does have policies and procedures in place to support this. The medication procedures in place were in line with the Royal Pharmaceutical Society of Great Britain. The Inspector looked at the entries on the Medication Administration Records and found them to be completed. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality of the service provided is good. Service User views are listened to and they are protected from abuse. EVIDENCE: The Deputy Manager speaks to Service Users regularly, either individually or in small groups regarding their care and wishes. The discussions are recorded in a notebook and signed and dated. The home has now implemented an individual finance recording form, the Inspector looked through them and they contained the income and expenditure with details of any transactions. The home did not have receipts for many of the transactions as Service Users did their own shopping and they did not remember to get one. The home has copies of the complaints procedure on display by the front door with spare copies available for family or visitors. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,28,30 Service Users live in a homely, comfortable and safe environment that is clean and hygienic. Service Users have sufficient bathrooms and bedrooms that suit their needs and promote independence. Communal space complements Service Users’ individual space. EVIDENCE: The home is homely, comfortable, clean, safe and free from offensive odours. Over the last 2 months the Fire extinguishers and lift have been serviced. The home has good access to a maintenance person and they have had the kitchen redecorated and a new carpet laid in the lounge. The railings at the back of the house have been replaced to increase security from the road. The home has ample bathrooms to meet the needs of the Service Users that allows them privacy. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 16 Service Users bedrooms are individualised and promote independence, the rooms were furnished with individualised personal belongings and were comfortable and clean. There is enough communal area that allows Service Users to access quieter areas if they wished to do so. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 The quality of service provided is good. Service Users are supported and benefit from a staff team who understand their role and are competent and effective. The homes recruitment process protects Service Users and they have their needs met by a trained and supervised staff team. EVIDENCE: The Inspector looked at a staff file and found it to contain the relevant information to conform to Schedule 2 of the Care Home Regulations 2001. The staff have recently had training in First Aid, Food Hygiene and Dementia, over 75 of staff have now achieved their NVQ level 2 or higher in care. The Inspector looked at staff files and saw supervision notes that were signed and dated. The staff files were stored individually in plastic folders in one folder. The inspector has asked the Manager to move them into individual files and that they are securely stored so that access can only be gained by the Manager or Deputy for purposes of confidentiality and Data Protection. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 18 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 The quality of the service provided is good. Service User benefit from a well run home and their views are listened to and acted upon. Service Users best interests are safeguarded by the homes record keeping, policy and procedures. Service Users benefit from caring and accountable management and their health, safety and welfare is protected. EVIDENCE: The home is run to benefit the Service Users, the care they receive is very good, in the past the recording has not matched the high standard of care given. The inspector looked at a lot of the recording and care plans and these have all been improved. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 19 The home needs to ensure that all records set out in Schedule 3 of Care Home Regulations are kept for each individual and regularly evaluated. The staff files were all kept in individually in plastic wallets and then kept together in one ring binder file. The file was stored with other records that allowed staff access to confidential staff details. The Inspector told the Manager that changes needed to be made. The Manager is to put the individual staff details into their own ring bind folder and store them in a locked cupboard with access only to the Manager and Deputy. The views of Service Users are listened to and are recorded and acted upon, the Deputy Manager speaks to Service Users on a regular basis and records any concerns or wishes so that they can be addressed. The Service Users 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. Service Users are protected by the homes policy and procedures and they have recently been updated. The Management of the home is still 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 application form for a Registered Manager is with the Deputy who is looking to return it in the near future. The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 3 2 3 3 The Mount And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 21 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. 3. Standard YA41 Regulation 17 Requirement Individual records and home records are secure, up to date and in good order; and are constructed, maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements. Timescale for action 30/09/06 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 YA41 Good Practice Recommendations The Registered person shall maintain in respect of each Service User a record that include 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.V296314.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 And The Olives DS0000024026.V296314.R02.S.doc Version 5.2 Page 23 - 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. 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