Inspection on 26/07/07 for The Mount Elderly Persons Home

This inspection was carried out on 26th July 2007.

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 Elderly Persons Home 03/08/06

The Mount Elderly Persons Home 31/01/06

The Mount Elderly Persons Home 30/08/05

The Mount Elderly Persons Home 14/02/05

The Mount Elderly Persons Home 17/08/04

The Mount Elderly Persons Home 08/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Mount Elderly Persons Home 136 Tennyson Road Luton Bedfordshire LU1 3RP Lead Inspector Mr Ian Dunthorne Unannounced Inspection 26th July 2007 10:00 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 Elderly Persons Home DS0000032878.V343091.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 Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Elderly Persons Home Address 136 Tennyson Road Luton Bedfordshire LU1 3RP 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) 01582 723944 01582 721217 annepalmer@luton.gov.uk Luton Borough Council Mrs Susan Stevens Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (40) The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No of residents: 40 Gender: Male and female Age: 65 upwards Category: Older people with Dementia and Residents who are over 65 years of age (OP and DE(E)). 3rd August 2006 Date of last inspection Brief Description of the Service: The home is situated on the outskirts of Luton, but still not too far from the town centre. Public transport did not stop close by and the home had to rely on other forms of transport. The size of the home affected the provisions positively as it was relatively easy to bring in additional services such as a GP, dentist, chiropodist, hairdressers, physiotherapist, district nurses etc. The home was in a building on three floors and the first two floors were used for residential purposes. The third floor was used for teaching computer courses and provided office accommodation for local resource managers and was not a resource used by the home. The building also housed a day centre that some residents attended along with residents from the wider community. The day centre was designed to accommodate 12 residents providing various activities. The manager also over sees the project but employed two staff to run the centre on a day-to-day basis. Information currently published and displayed in the homes ‘Service User Guide’ regarding the home’s range of fees and the manager’s figure provided during the inspection stated that the weekly fee was £600. These fees did not include newspapers, hairdressers, personal telephone, toiletries or private chiropodist; these services would incur an additional charge. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven hours during the morning and afternoon and it was unannounced. Prior to the inspection time was taken to review the information gathered since the last inspection and plan this inspection visit. This report also includes feedback from relatives and visitors obtained from postal surveys. The inspection included a tour of the communal areas and several bedrooms, inspection of certain records, discussion with staff and the manager, discussion with residents, their relatives and observation of the routines of the home. The method of inspection was to track the lives of several residents. This was done by speaking to them about the service they receive, observing their life in the home, talking to staff and relatives and reviewing their records. The inspector was accompanied during this inspection by an ‘expert by experience’ for three hours from ‘Help the Aged’, who made observations, spoke to residents, staff and relatives about life at the home, based on information and areas of focus provided by the lead inspector. What the service does well: The manager said that they provide an individual needs led service for residents; this was supported by evidence during the inspection. The home had effective methods of communication with relatives, which had helped them build good relationships and the home kept relatives informed of any changes and welcomed them into the home with unrestricted visiting times. One relative said, “they always keep me informed and updated either by phone or when I visit the home”, another relative said “they always phone me and keep in contact if there are any changes, they have been a life saver for me”. The home made sure that residents wishes upon death or terminal illness were taken, respected and recorded. All staff were observed throughout the inspection to have formed good relationships and a good rapport with residents, including those on respite care. One relative commented in their survey response ‘the staff here are so supportive at all times’. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 6 The home provided suitable arrangements for resident’s leisure and activities, which suited their individual needs and preferences. The home placed importance upon focusing on activities for the residents. The home had received no complaints since the last inspection and the home had a positive approach to complaints and made sure people knew how to complain. One relative said, “I feel I can speak to any of the staff and I know how to complain, they are all very approachable” What has improved since the last inspection? What they could do better: Some of the things that the home could do better include: • Asking for the views of others about what they think of the home and any suggested ideas for improvement. Then producing a plan, showing how they will act upon those views and carry the plan out. Ensuring that medication is properly and safely looked after and that clear, accurate records are kept and that staff are assessed as competent. Making sure staff are suitably trained to prevent fire. DS0000032878.V343091.R01.S.doc Version 5.2 Page 7 • • The Mount Elderly Persons Home • • Making sure the garden area outside is safe and accessible for residents to benefit from and enjoy. Ensuring all specialist bathing facilities for residents are safe for them to use and safe for staff to assist and provide support in them, when required. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Mount Elderly Persons Home DS0000032878.V343091.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 Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided information about its facilities and services, which were supported by needs assessments to enable prospective residents to make an informed decision about admission to the home. EVIDENCE: The homes ‘Statement of Purpose’ was displayed with a copy of the last inspection report in the homes entrance area. However the manager acknowledged that they could be better at ensuring information contained within the ‘Service User Guide’, which supported the ‘Statement of Purpose’, was up to date and it was not always in a suitable format for the residents, this was a recommendation at the last inspection. Most respondents to the surveys sent to the residents, said that they felt they were given enough information about the home to make informed choices. Relatives who were spoken with as part of the inspection supported that evidence. All the relevant information had been included in the information provided by the home. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 10 Evidence examined confirmed that the residents whose lives were tracked had written contracts with the home, provided with a statement of terms & conditions at the point of moving into the home; this included the fee details and also applied to and included those residents on a short-term placement for respite. The resident or their representative, who authenticated and confirmed their agreement with the terms and conditions, had signed the contracts examined. There was evidence that the home had undertaken an assessment of the needs of residents on admission; this included a resident on a short term, respite placement and a resident recently admitted. They had also been provided with a summary assessment from the referring care management service, which they had used to form part of the information that contributed to their own needs assessment and subsequent supporting care plan information. Those records examined of the residents whose lives were tracked, had been in some cases signed by the relative on behalf of the resident as their representative, which confirmed they had been consulted, and their agreement sought. The home did not admit residents for intermediate care. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis and the staff have a good understanding of residents support needs, evident from positive relationships which have been formed between staff and residents. EVIDENCE: A sample of the resident’s care plans were reviewed and found to contain good information to help meet their daily needs. There was evidence that the resident or their representative had been involved in compiling the resident’s care plan by consultation and agreement indicated by signing it in most cases and that they had been reviewed regularly. The resident or their representative had been involved in the reviews and consulted about any changes made to the service user plan, this was verified by those relatives who were spoken with and in addition were supported by annual review records. However the care plans had not been recorded in a style, which was accessible to all The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 12 residents. The risk assessments supporting the residents care plans had been reviewed regularly; this included falls and extended to footwear. The health care needs of the residents were met by the home satisfactorily. Residents weight had been monitored which supported other records completed by the home, including food intake monitoring charts and nutritional needs care plans when required. There was evidence that falls risk assessments had been completed for residents. Evidence available supported the fact that residents were enabled by the home to access a variety of health care services, to meet their assessed needs. All respondents to the postal surveys said they felt that the home met the medical support needs of the resident. No residents were self-medicating at the time of this inspection. Samples of medication records, storage and procedures were checked, of those residents whose lives were being tracked as part of this inspection. Each resident’s mar sheet included an accompanying photograph for identification purposes. Controlled drug records and balances were checked and found to be satisfactory. Residents are protected by adequate security of medicines and the temperature of the storage facilities ensures the quality of medicines in use. The temperature of the storage room must be monitored and recorded regularly to show that medicines are constantly stored under suitable conditions, as there was no evidence to support this. The temperatures of the refrigerators used to store medicines were recorded and were within recommended acceptable limits. The home had a system for administering and applying topical treatments to residents, however the treatment records for this system did not accurately reflect the prescribed details. Only trained staff were allowed to give medicines to residents and observation of this showed that residents choice and dignity was respected. The training of care staff on the safe use of medicines is evidenced by attendance on relevant courses but there was no clear assessment of competence that staff can put this knowledge into practice. This is, however, planned for the future and the manager acknowledged that this was necessary and was able to provide evidence of two staff members completed competency based tests as an example of this commitment. The evidence from speaking with some residents and relatives was that the residents were treated with respect and their rights to privacy were upheld and this was consistent with the relatives and visitors survey responses and observations made during the inspection. The expert by experience commented in their report that ‘There seemed to be a caring and concerned One relative commented “the staff are very kind and helpful and mum is always clean and tidy and they always involve us in any decisions about her, all the family and mum are very happy”. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 13 culture; I found the staff I talked to/observed to be caring, committed and helpful. The residents were well dressed.’ Staff were observed knocking on residents bedroom doors, bathrooms and toilets before they entered. The home had a death and dying policy and there was evidence that residents wishes that in the event of terminal illness or death was recorded. This information was included within residents care plans and the resident or their representative had signed them. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The meals in the home were good, offering a varied selection of food and catering for special dietary needs. However the menu format, tool and method of delivery required further development, to help residents to understand the menu choice they were making, to ensure they chose a meal they wanted. EVIDENCE: During the inspection some residents downstairs were observed in the morning and afternoon participating in planned activities. A part time activities organiser in a dedicated activities room was providing the activities. There were opportunities for some residents who were able, to attend the day centre at the home. An activity plan was available to examine. There was some evidence that residents were given the opportunity to go on planned trips and outings, provided and arranged by the home; information was displayed. However the manager felt that further improvements could be made in this area to increase external outings and trips for residents, this view was also held by some staff who were spoken with. The manager also said that she hoped to increase the hours of the activities organiser to full time. Relatives The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 15 spoken to during the inspection said independently, that they felt the home made suitable and sufficient activities available to the residents. One relative commented that the home held meaningful activities; including art classes and that staff knew how to stimulate the residents. The home observed residents religious needs satisfactorily. Evidence suggested that resident’s were able to maintain regular contact with their relatives and friends without restrictions and were supported to maintain contact if they wished, by the home. Relatives who responded to the postal surveys also supported the evidence and said they felt welcomed by the home when visiting and knew that they could visit at any time. They also said that staff always kept them informed and updated when visiting. Some residents were supported to maintain contact with community links, demonstrated by one resident with an ‘Age Concern’ representative. The home was able to demonstrate that they supported residents to maintain as much choice and control over their lives as possible in most areas. Residents’ bedrooms were individualised with personal possessions and all those resident’s relatives who were spoken with said that they were encouraged to bring in the residents personal effects. Meetings facilitated by the home for the residents were held on a regular basis. There was evidence that an advocacy service visited the home on an ‘as required’ basis. Some observations were made over the lunch; afternoon tea and teatime periods during this inspection and residents appeared unhurried by staff during this time. Resident’s were observed being offered a choice of meals and beverages and those with dietary or cultural needs were being accommodated for. One relative commented in their survey response “they were particularly helpful in arranging suitable food for my husband, who cannot chew properly” The home had produced large format menu’s to enable more residents to choose from the menu, however this would only be suitable for those with sensory type impairments and not necessarily improve choice for residents with dementia. The home offered suitable food portions that were well presented. Staff were observed assisting resident’s who required support to enjoy their meals appropriately and sensitively and there were enough staff to ensure residents were suitably supported and their dignity maintained. Residents spoken with said they enjoyed the meals at the home and one said to the ‘expert by experience’ when asked if they had a choice “will bring something else [if not liked]”. There was evidence that there were some limitations on how residents were enabled to make an informed choice about their menu selection on any given day and methods of how they were consulted. Practical tools to improve how residents are enabled to make an informed choice could be improved further. This was a recommendation at the last inspection and led to the introduction of large format menu’s as described above, demonstrating the home’s responsible and pro-active approach to methods of improvement. The expert The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 16 by experience commented in their report ‘on daily menu choice I was told that much is known individually of needs and preferences. Staff said that there was choice and for example one resident had asked for and received a beer. Whilst acknowledging the difficulties and constraints I wasn’t convinced that the minority capable of making a choice - even if just before the meal - were regularly able to make that choice.’ Seasonally suitably amended menus were not available, this was a recommendation at the last inspection, however alternatives were available on the daily menu, which could be requested. Although this option was then in conflict with how residents are enabled to make an informed choice, as described above. The expert by experience commented in their report ‘The menu is on a 4 weekly cycle and I’m told that it is changed about once a year.’ A regulatory inspector from the ‘Environmental Health Office’ had visited that morning and their preliminary report, which was left as feedback from their inspection visit was observed to describe a ‘good standard’. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had an open, transparent and pro-active approach to how it received and managed complaints. There was evidence that residents and relatives felt their views were listened to and acted upon. EVIDENCE: The home had received no formal complaints since the last inspection. A record was kept of all concerns & complaints. The home had a satisfactory complaints policy and procedure in place, which enabled them to deal with complaints received. Relatives spoken with were aware of the home’s complaints procedure and felt comfortable and confident to use it and that they would be listened to. The homes complaints procedure information available to residents, relatives and visitors on the day of the inspection, was available and displayed in the home’s reception foyer. Information of how to complain was also included in the information provided to resident’s and or their relatives / representatives on the residents admission into the home. All respondents to the postal surveys said they knew how to complain and who to speak to if they weren’t happy, those residents and relatives verified this evidence that were spoken with during the inspection. The home had satisfactory procedures in place to safeguard residents from abuse. Most staff had received Safeguarding Adults training. All care staff spoken with knew what to do in the event of witnessing an alleged incident of The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 18 abuse occurring. Since the last inspection there had been four notifiable incidents in accordance with the Safeguarding Adults policy and guidance, which was reported to CSCI (Commission for Social Care Inspection) at the time. Evidence examined, supported a process that had been followed to safeguard and protect residents. There was evidence that some staff had received training to support them to understand and deal with any aggression demonstrated by a resident appropriately, including how to diffuse challenging situations. This training was in addition to and supported training in dementia care that was already provided. However, the manager said that training was not always available when required, in a timely response to the requests being submitted. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home was satisfactory. However there were some identified risks, which need to be addressed, to minimize potential risk to residents and safeguard their health and physical well being. EVIDENCE: The home had a maintenance person based at the home who followed a maintenance program. At the time of the inspection the maintenance person was in the process of decorating the ground floor corridor. There was evidence during the inspection that a rolling program of maintenance and improvement would soon begin at the home in the form of a zoned refurbishment program; the middle floor was planned to commence during September / October this year. It was evident that some improvements had been made since the last inspection, such as the entire commode chairs in residents’ bedrooms had The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 20 been replaced and new dining tables and armchairs for communal areas had been replaced and provided. The expert by experience commented in their report, ‘A tour of the premises revealed significant refurbishment since the last report. Plenty of new and attractive tables and dining and easy chairs were evident; this together with extensive redecoration created a friendly and welcoming ambience.’ Non-slip laminate flooring had been fitted to the corridor areas on the first floor, which appeared homely, fresh and clean and the benefits expressed by all those spoken to were positive. Changes to how the home was divided and separated internally had recently been made and implemented; to improve how the home met the residents individual and collective needs in a comfortable and homely way. The changes made had clearly benefited the residents and positive comments were made about the changes by relatives and staff. The expert by experience commented in their report, ‘the staff I talked to were most enthusiastic about this system that helped considerably with calming the atmosphere both for these 12 residents and the others on the floor below. In fact the atmosphere throughout was much calmer than I had expected.’ The home had replaced some communal furniture which was a requirement at the last inspection which had subsequently now been complied with. However improvements to make the main outdoor garden area safe and accessible for residents had not been made, which was a recommendation at the last inspection. Residents, relatives and staff alike, all expressed their dissatisfaction with this poor progress. However it was understood that improvement works are intended to commence in September this year, by external grounds maintenance contractors. Several toilets were observed to be tastefully decorated. One bathroom that had previously been refurbished on the ground floor was not fit for purpose, as it was unsafe for residents and for staff to provide assistance; this was made a requirement at the last inspection that had not been complied with; the manager said that this specialist shower room was not used as a result. Two bathrooms located on the first floor, previously not used as they were not suitable to meet the residents’ needs had been improved and adapted and were now safe and suitable and were used and benefited residents. Several bedrooms were inspected during the inspection and were all found to suit the needs of the residents. The décor was suitable and some re-decoration in places was relatively recent. Residents bedrooms were personalised see ‘Daily Life and Social Activities’ section of this report and where necessary specialist equipment was used to maximise their independence. All commode chairs in residents bedrooms had been replaced since the last inspection, which was a previous requirement made, which had now been complied with. The expert by experience commented in their report ‘All of these rooms were well decorated and pleasantly furnished’ The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 21 The home appeared suitably clean and free from offensive odours, more suitable flooring had been fitted on the first floor since the last inspection, which made the area appear clean & pleasant. All respondents to the postal survey questionnaire’s stated that the home was always fresh and clean. Training records identified some staff that had undertaken infection control training. The expert by experience commented in their report that ‘I was not aware of any odours in the communal areas’ The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were enough qualified staff to ensure the needs of the residents could be met and the home ensured that the residents were protected by their robust recruitment practices. EVIDENCE: The home provided sufficient numbers of staff to meet the ratio of residents in the home. On the day of the inspection nine care staff were available from 7.30am time to meet the needs of thirty-five residents decreasing to eight staff at 10.30am and reduced during the afternoon and evening to seven staff these staff ratio’s excluded the duty senior. The home had recently begun the integration of re-deployed staff from two local authority homes as a result of their planned closures, which had previously prevented them from recruiting their own staff as the posts were ‘frozen’ in anticipation of the re-deployed staff. Consequently the home only had one vacant permanent care post of twenty hours per week. Staff spoken with said about staffing levels that “things are a lot better now” and staff felt that they were able to meet the residents needs as a result. All survey respondents said that there were staff available when they needed them and relatives who were spoken with supported this. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 23 Subsequently, the homes agency usage had decreased dramatically which was reflected in the care home’s rota, the manager said that agency staff were now only necessary sometimes to cover permanent staff’s annual leave. Training records detailed evidence that over 75 of care staff had achieved NVQ level 2 or above. Staff records examined indicated that the homes recruitment procedures were satisfactory. Staff that were spoken with supported this evidence. The training provided was varied and relevant, which helped to enable staff to be competent to do their jobs and included some specialist training such as nutrition & dementia. Staff members spoken with reported various training which they attended, including some recently. There was evidence that the home provides staff with ‘Skills for Care’ induction & foundation training. This was in addition to and supported the home’s own induction training, which also included the local authorities corporate induction day. However there were no specific training records relating to health and safety identified and it appeared that only ancillary staff were provided with the opportunity to complete COSHH (control of substances hazardous to health) training. In addition it was a recommendation at the last inspection that suitable arrangements should be made to ensure staff complete fire prevention training, however there was no evidence that the home had made any improvements or achieved this. See ‘Management & Administration’ section of this report. It was explained that some elements of this training were incorporated within the general corporate induction from the local authority, however this was not specific or measurable. The home provided a training & development plan for each individual staff member, which formed part of their annual appraisal process and records. A training matrix was in place which identified all staff’s training records and consequently any deficits or refreshers due. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager was supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. In addition the manager had a good understanding of the areas in which the home needed to improve and planning was in place that identified how this would be managed. EVIDENCE: The manager Susan Stevens was present for most of the inspection. The manager said that she had NVQ level 4 in both care and management and had completed her Registered Managers Award. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 25 The manager was observed to communicate effectively with both residents and staff and appeared approachable. Residents and staff who were spoken to supported this view. The home had an inclusive atmosphere. The manager of the home maintained an effective leadership ethos that both residents and staff were able to benefit from. The expert by experience commented in their report, ‘A pleasant surprise to find how positively the home had progressed and developed the environment and internal organisation for the improved benefit of the residents.’ Developing and maintaining an effective quality assurance system within the home, was set as a requirement at the last two inspections and had only been partially complied with. There was evidence that the manager had made some further progress since the last inspection but had yet to complete the full quality monitoring cycle, by developing a form of annual development plan with the results, which could then be maintained systematically. Results of the last surveys that the home sent to relatives, visitors and external professionals were sampled and demonstrated positive feedback about the service and care provided, this information had been translated by the manager into graph form. Relatives and visitors were actively encouraged to provide feedback to the home, which was demonstrated by a notice displayed in the reception foyer, advising those who wished to, how to provide complaints, compliments and suggestions. Residents’ financial records and secure safekeeping of money and valuables, were being maintained satisfactorily on behalf of the residents by the home, individual receipts and transaction records were now being kept for each resident. The residents financial interests were safeguarded by the home, this protected the interests of the resident. However, although each resident benefited from an individual statement for their personal allowance bank account, the ‘pool’ bank account arrangement did not enable residents to benefit from individually accrued interest. Although the bank account was maintained by the home, they did not have the authority to change this arrangement. Staff spoken with said they were receiving supervision, although the regularity could fluctuate sometimes, but was generally regular. This was supported by recorded evidence sampled, which included records of annual appraisals. Staff spoken with said there was regular staff meetings. Some records it was noted had a number of entries made by staff that had signed to authenticate care records using various forms of abbreviations of their names, or variations of their initials only, as opposed to their full names for clear identification purposes. In addition several daily care records and care plans of residents examined, demonstrated that a generic system of abbreviations were used by care staff when recording. The homes smoking and alcohol policy was examined, which had recently been revised and was found to be suitable for the home and to meet the needs of the residents without The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 26 compromising health & safety. The home maintained an inventory of resident’s personal belongings, to ensure their protection and safety. There was evidence that the home maintained general risk assessments, including health & safety and fire, in addition the manager said that fire risk assessments were being introduced for each resident. Staff did not receive measurable health & safety or suitable fire prevention training; see ‘Staffing’ section of this report. One aspect of the homes health & safety safe working practices, required some improvements to protect residents from potential risk or harm; see ‘Environment’ section of this report regarding the specialist bathing facility. Staff had received training in safe moving & handling, infection control management and safe food hygiene practices, in accordance with the home’s risk assessments and policies. Various records were examined to support adequate compliance with safe working practices, regarding health & safety. The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 27 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 3 2 2 The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 13(6), 18 (1) (a) Requirement All staff who are authorised to administer medicines must be assessed that they are competent to do so. Medication administration records maintained by the home must accurately reflect the prescribed dose and frequency. Timescale for action 30/09/07 2. OP9 13 (2) 31/08/07 3. OP20 23 (2) (o) Outdoor space for residents must 30/09/07 be accessible and meet the needs of all residents, including those with physical, sensory and cognitive impairments. Sufficient and suitable bathing facilities must be provided to meet the needs of the residents. Previous timescale 30/11/06 not met. Effective quality monitoring systems must be implemented in the home to ensure satisfactory service delivery is maintained. Previous timescales: 30/03/06 & 30/11/06 met in part. DS0000032878.V343091.R01.S.doc 4. OP21 23 (2) (j) 31/10/07 5. OP33 24 (1) (a) (b) 31/10/07 The Mount Elderly Persons Home Version 5.2 Page 29 6. OP38 23 (4) (d & (e) Suitable arrangements must be made for staff to receive fire prevention training. 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The home should keep under review and where appropriate revise the statement of purpose and the service user guide. Information about the home including residents’ contracts & the service user’s guide should be made available in formats suitable for each resident. Care plans should be produced in a format, which is accessible to individual residents, to provide them with every opportunity to be consulted, understand and agree to their care. The home should monitor and record the medication storage room temperature daily, to ensure it does not exceed the recommended safe limits. A menu to suit the capacities of all the residents should be provided to enable the residents to make a decision. A seasonal variation or option to the choice of meals provided should be offered to ensure a varied & appealing diet for residents. Care staff should ensure that they sign documented care records with their full name on each entry and generic use of abbreviations should be avoided, as this can prevent residents understanding information held about them. 2. OP7 3. OP9 4. 5. OP15 OP15 6. OP37 The Mount Elderly Persons Home DS0000032878.V343091.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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. 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