Inspection on 03/08/06 for The Mount Elderly Persons Home

This inspection was carried out on 3rd August 2006.

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

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

Other inspections for this house

The Mount Elderly Persons Home 26/07/07

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 8th August 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Mount Elderly Persons Home DS0000032878.V304332.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.V304332.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 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.V304332.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 Service Users who are over 65 years of age (OP and DE(E)). 31st January 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 was not a resource used by the home. The building also housed a day centre that some service users attended along with service users from the wider community. The day centre was designed to accommodate 12 service users 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 ‘Statement of Purpose’ regarding the home’s range of fees and the manager’s figure provided in the pre-inspection questionnaire in July 2006, both 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.V304332.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 nine hours during the morning, afternoon and early evening 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 comment cards. The inspection included a tour of the communal areas and several bedrooms, inspection of certain records, discussion with staff and the manager, discussion with service users, their relatives and observation of the routines of the home. The method of inspection was to track the lives of several service users. 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. What the service does well: What has improved since the last inspection? The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 6 The meals were served suitably hot for service users to enjoy. The home had made sure that service users wishes upon death or terminal illness were taken respected and recorded. More suitable flooring had been fitted on the ground floor, which made the area appear clean & pleasant. What they could do better: Some of the things that the home could do better include: • Making sure that service users who stay for a short time have a written contract and that all service users including short term ones, are clear about anything they will have to pay for. Ensuring enough staff are available to meet the needs of the people living the home. Providing training for staff, which would help them understand and meet some of the specialist needs of the people living at the home. Ensuring that the home is safe for service users and staff to live and work in. Making the home a pleasant homely place to live throughout. Asking for the views of service users and 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 looked after and that measures are in place to ensure it does not go out of date. Making sure the garden area outside is safe and accessible for people living at the home to benefit from and enjoy. • • • • • • • 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 Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 7 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.V304332.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ The home provided sufficient information for prospective service users, however it sometimes failed to identify the fees payable, which did not allow all service users to be aware of the fee and what they may need to pay. The information also needed to be updated, to ensure service users received the correct details. EVIDENCE: The homes ‘Statement of Purpose’ was displayed with a copy of the last inspection report in the homes entrance area. However the ‘Statement of Purpose’ was out of date in some areas and required updating, to ensure it provided the correct information. Each permanent service user had a contract in the form of a statement of terms and conditions. However further development was needed to ensure contractual agreements were also provided for short-term service users. The home failed to include the fees payable within the terms and conditions in some cases. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 9 There was evidence that the home had undertaken an assessment of the needs of each service user on admission, which included a respite placement, admitted at short notice. The home demonstrated that it was able to meet the assessed needs of individual service users satisfactorily. This included some specialised services such as for people with dementia, a service user from a specific ethnic minority community and respite care. The home did not admit service users for intermediate care. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ Service user plans were satisfactory to meet the daily needs of service users, although further development was needed to ensure any changes to plans, included the service user or their representative for their agreement. Associated risk assessments needed to ensure their information contained accurate, detailed action and risk rating, to effectively reduce risks associated with service users health care needs. EVIDENCE: A sample of the service user’s plans were reviewed and found to contain good information to help meet their daily needs. There was evidence that the service user or their representative had been involved in compiling the service user plan and that they had been reviewed regularly. However the service user or their representative had not been involved in the reviews, or consulted about any changes made to the service user plan. The risk assessments supporting the service user plans had been reviewed regularly; however further development was needed to ensure they contained more detail regarding action & outcome and a risk rating that accurately reflected the risk. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 11 The home had not been completing service user plans for respite care service users since the last inspection. One respite service user whose life was tracked did not have a service user plan. There was a needs assessment checklist document in place, which the home thought was suitable for a respite care service user and was considered the plan. However the information was limited and did not contain enough information with detailed action, to ensure the daily needs of respite care service users would be met. The health care needs of the service users were generally met by the home satisfactorily. Further development was needed to ensure falls risk assessments were completed adequately and that actions & outcomes were recorded and implemented. The home was also able to identify when they could not meet the needs of service users and had made arrangements for these service users to receive alternative placements to continue their care. Records examined and the staff handover that was witnessed, demonstrated that the health care needs of service users were reviewed and addressed. No service users were self-medicating at the time of this inspection. Samples of medication records, storage and procedures were checked, of those service users whose lives were being tracked as part of this inspection. All staff administering medication had received training. The home had implemented some effective procedures when administering medication, to help prevent service users from risk and to reduce the risk of a potential administration error by the home. One medication trolley was padlocked to the wall in a corridor and was not stored in a lockable room. Liquid medications were not always being dated when opened by trained staff, which did not allow them to identify when the medication was ‘out of date’. This also applied to topical creams and treatments which were being applied, which were again not being dated when opened by staff. The evidence from speaking with some service users and relatives was that the service users were treated with respect and their rights to privacy were upheld and this was consistent with the relatives and visitors comment card responses. One relative said “ I very much feel staff treat my relative with dignity and respect”. However, observation during lunchtime demonstrated that several service users were prevented from maintaining their dignity whilst eating due to an absence of tabards or food aprons, which some service user plans identified should be worn. It was also observed during lunchtime that not all service users were enabled by the home to maintain their dignity fully. The home had made significant improvements to identify service users wishes in the event of death or terminal illness since this requirement was set at the last inspection. This information was now included within service user plans and they had been signed by the service user or their representative. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ The meals in the home were satisfactory, offering a varied selection of food and catering for special dietary needs. However the menu format required further development, to help service users to understand the menu choice they were making, to ensure they chose a meal they wanted. In addition, the menu only provided service users with a hot main dinner choice, which did not offer a seasonally appealing or appetising choice. EVIDENCE: During the inspection some service users downstairs were observed in the morning and afternoon participating in planned activities. The activities were being provided by staff on the day of the inspection, as the activities organiser was not available. There were opportunities for some service users who were able, to attend the day centre at the home. An activity plan was available to examine and an activities organiser was employed by the home and shared with another Luton Borough Council home. There was some evidence that service users were given the opportunity to go on planned trips and outings, provided and arranged by the home; information was displayed. Relatives spoken to during the inspection said independently, that they felt the home made suitable and sufficient activities available to the service users. The home observed service users religious needs satisfactorily. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 13 Evidence suggested that service users 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 were spoken to during the inspection 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 made time to talk to them. The home was able to demonstrate that they supported service users to maintain as much choice and control over their lives as possible in most areas. Service users’ bedrooms were individualised with personal possessions and one service users relative said that they were encouraged to bring in the service users personal effects. One area that did not evidence service users choice and control was that the home purchased toiletries for some service users on their behalf using a ‘multi buy’ system, as it was described as cost effective. However, there was no evidence that service users were able to choose which toiletries were purchased and it did not take into account all service users individual choices. Although it was explained that if a service user wanted an alternative product, their keyworker could purchase this for them instead. Following a requirement set at the last inspection regarding food temperature when served, the temperature records were checked and found to be satisfactory. Service users, relatives and staff spoken to, supported evidence that the food temperature was suitable. Menus examined generally offered choice and a nutritious and wholesome diet to the service users, with a balanced and varied selection of foods. However every main dinner detailed, was a hot choice and it did not contain any seasonal alternatives to this, although evidence supported that cold alternatives were provided if requested. The menu’s were not written or presented in a format that was suitable for the capacity of all service users. Staff spoken to said they did explain the menu’s to service users and showed them the meals if necessary before serving them, to enable service users to maintain their choice. Staff were observed assisting service users who required help and those with dietary needs were accommodated for; the liquefied meal of one service user was observed to be well presented. Observations were made over the lunchtime period during this inspection, as mentioned previously in ‘Health & Personal Care’ section of this report. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ The home had satisfactory complaints and adult protection procedures in place, which ensured that complaints were listened to and service users could be safeguarded from abuse. However some staff had not received POVA (‘Protection of Vulnerable Adults’) training which could place service users at possible risk of harm or abuse. EVIDENCE: The home had received no complaints since the last inspection. A record was kept of all complaints. The home had a satisfactory complaints policy and procedure in place, which enabled them to deal with complaints received. Relatives spoken to were aware of the home’s complaints procedure and felt comfortable and confident to use it and that they would be listened to. The home had satisfactory procedures in place to safeguard service users from abuse. Almost all care staff had received POVA (Protection of Vulnerable Adults) training. However several ancillary & support staff had not received training and some had been employed for a considerable time. Most care staff spoken to knew what to do in the event of witnessing an alleged case of abuse occurring. This included one recently employed staff member who was spoken to and who had received training. The home had one reportable POVA incident since the last inspection, which was reported to CSCI at the time and has not been concluded. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 15 Money held by the home for two service users whose lives were tracked, was checked and balanced with the records held. The money was stored safely and individually for each service user. There was evidence that the money and records were being monitored and checked by the manager periodically. This was to ensure that the records and money held was correct as part of a self audit process. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 26 ‘Quality in this outcome area was poor. This judgement was made using available evidence including a visit to this service.’ There were identified risks and a poor standard of décor in various areas of the home and the ‘tiredness’ of those areas detracted from the homeliness of the environment. EVIDENCE: The home had a maintenance person based at the home who followed a maintenance program. However, the manager explained that external contractors maintained the decoration in some areas and there was clear evidence that in those areas of the home, this was not being maintained adequately. As a result the home appeared tired and poorly maintained in those areas. Service users were able to access the stairs from the ground floor; the manager said this had been risk assessed and the home was waiting for a security keypad to be fitted to the door enabling access to the stairs. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 17 Non-slip laminate flooring had been fitted to the corridor areas on the ground floor, which appeared homely, fresh and clean and the benefits expressed by all those spoken to were positive. A requirement had been made at the previous inspection, which had not been complied with by the home regarding dining tables. The home had tried to modify the tables to meet the requirement by stapling plastic tablecloths to the tables, but this had failed. The home had tried to regulate the temperature of the home during the summer months using air conditioning units in communal areas. However the units were on wheels with no brake system and were accessible to service users and the risk had not been assessed satisfactorily. Both staff and relatives had raised concerns that the home had insufficient numbers of armchairs available and this was observed to be the case during the inspection. The home had a small patio area outside which was accessible and safe for service users to make the best use of it. However, the main garden area at the rear of the building next to the patio was not accessible, as the ground was uneven and it had not been rectified by grounds maintenance work, preventing service users from safe access. Several toilets were observed to be tastefully decorated. One bathroom that had been recently refurbished on the ground floor was not fit for purpose, as it was unsafe for service users and for staff to provide assistance. Another bathroom located on the first floor was not used, as the manager said it was not suitable to safely meet service users needs. Staff were observed wearing specialist moving and handling equipment. Several hoists were observed being used and staff appeared to be using them in accordance with safe moving and handling techniques. Several bedrooms were inspected during the inspection and were all found to suit the needs of the service users. The décor was suitable and some redecoration in places was relatively recent. Service users bedrooms were personalised see ‘Daily Life and Social Activities’ section of this report and where necessary specialist equipment was used to maximise their independence. Some commode chairs appeared old and worn and in some cases effective infection control methods were compromised, due to the condition of the chairs. The home was clean and free from offensive odours except the activities room, which was found to have an offensive odour. Some bins provided in toilets were unsuitable for the control of infection. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 ‘Quality in this outcome area was poor. This judgement was made using available evidence including a visit to this service.’ Staffing levels within the home were not always evident to meet the needs of the service users, which could place them at risk of harm. The level of specialist training provided for staff to meet the needs of the service users was poor, which could also place them at risk of harm. EVIDENCE: The home provided sufficient numbers of staff to meet the needs of the service users. On the day of the inspection six care staff and three team leaders were available to meet the needs of thirty-three service users, there were also a sufficient number of auxiliary staff. The manager said there was one hundred and sixty vacant care assistant hours per week, which were mainly being covered by staff working overtime and agency staff. The vacant positions were ‘frozen’ which prevented the manager from recruiting. Five out of fifteen relatives / visitors comment cards received, expressed concern that there weren’t always sufficient numbers of staff on duty, the concerns were also supported by those relatives spoken to during the inspection. It was observed during the afternoon that whilst a sufficient number of staff were on duty within the home to meet the needs of the service users, only one was present to meet the needs of ten service users for a period of thirty minutes. Demonstrating that the ratio of care staff present at that time to meet those service users needs was insufficient. It was evident that the level The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 19 of need of several high dependency service users, impacted upon the amount of care provided for the remaining service users. Training records detailed evidence that more than 50 of care staff had achieved NVQ level 2 or above. The homes recruitment procedures were satisfactory. One staff member’s file inspected, demonstrated that the home had identified an out of date work permit and had asked the staff member to refrain from work until it had been re-issued. Staffs records inspected, showed evidence of individual training and development plans. Staff members spoken to reported various training which they attended, including some recently. However, many staff had not received fire safety training. One staff member spoken to said she had been told what the home’s fire procedures were but had never received training. The training matrix examined for all staff provided evidence that many staff had not received fire training. The manager said these courses are external and so are reliant upon when they arise and how many places are available. There was evidence that the home provides staff with ‘Skills for Care’ induction & foundation training, although the manager acknowledged that the home has some difficulty monitoring staff’s progress and completion of the training. Therefore these are not always completed within the ‘National Training Organisations’ (NTO) specified targets. The home failed to provide a satisfactory level of training for staff in dementia care. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ Service users’ views were sought but there was no evidence that this changed how the home was run. The homes risk assessments, food hygiene and management of service users money procedures; needed further development to ensure service users & staff would be protected from harm and service users from illness and abuse. EVIDENCE: The manager Susan Stevens was present for the afternoon and early evening part of the inspection. The manager said that she had NVQ level 4 in both care and management and has completed her Registered Managers Award. The manager was observed to communicate effectively with both service users and staff and appeared approachable. Service users and staff who were spoken to supported this view. The home had an inclusive atmosphere. The The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 21 manager of the home maintained an effective leadership ethos that both service users and staff were able to benefit from. Developing and maintaining an effective quality assurance system within the home, was set as a requirement at the last inspection and had still not been complied with. There was evidence that the manager had made some progress since the last inspection but had yet to complete the full quality monitoring cycle, which could then be maintained systematically. Service users financial records and secure safekeeping of money and valuables were being maintained satisfactorily in most areas on behalf of the service users by the home. See also ‘Complaints & Protection’ section of this report and ‘Daily Life & Social Activities’ section of this report. Two areas that were not satisfactory were firstly a communal receipt book was being used by the home for recording the visiting hairdresser’s services and payments. This was not satisfactory to maintain clear individual financial transaction records for each service user And secondly, the bank account maintained by the home for service users personal allowances was a ‘pool’ account. Therefore the home explained that this prevented interest being accrued for individual service users. Staff spoken to said they were receiving regular supervision. This was supported by recorded evidence on staff files. Staff spoken to said there was regular staff meetings. There was evidence that the home maintained general risk assessments, including health & safety and fire, however the level of risk is not always clearly identified and they were not all completed appropriately. There was some evidence observed within the home’s main kitchen and other areas of the home that safe food hygiene practices were not being consistently maintained by staff. Various records were examined to support adequate compliance with the following safe working practices, regarding health & safety including; lift certificate, accident records, fire test and inspection records and a generic emergency / crises contingency plan. The home’s generator did not support the ‘nurse call’ system in the event of power loss to the home; this became apparent as a result of a notifiable incident reported earlier in the year. However a risk assessment had still not been completed by the home, in the event that this should occur again in the future. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 1 2 3 X 2 X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 2 3 X 2 The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 (1) (b) & (c) Timescale for action Provide service user contracts for 31/10/06 those service users on shortterm placements, including the amount and method of payment of fees. Service user plans must be 31/10/06 completed with each service user or their representative and kept under review in consultation with the service user or their representative. Staff must adhere to the homes’ 30/09/06 policies and procedures for the receipt, recording, storage, handling, administration and disposal of medicines. Arrangements must be made to 30/09/06 ensure the privacy & dignity of service users during mealtimes is maintained. Arrangements must be made to 31/10/06 replace or make good the existing dining tables used by the service users for meals. Previous timescale: 30/04/06 A programme of maintenance 30/11/06 must be provided and implemented, to include the plans for renewal of the DS0000032878.V304332.R01.S.doc Version 5.2 Page 24 Requirement 2. OP7 15 (1), (2) (c) & (d) 3. OP9 13 (2) 4. OP10 12 (4) (a) 5. OP19 23 (2) (b) 6. OP19 23 (2) (a) & (b) The Mount Elderly Persons Home 7. OP20 16 (2) (c) 8. OP21 23 (2) (j) 9. OP24 23 (2) (c) 13 (3) 10. OP27 18 (1) (a) 11. 12. OP30 OP33 18 (1) (c) (i) 24 (1) (a) (b) decoration of the premises where a need is identified. Suitable chairs in sufficient numbers must be provided in communal areas occupied by service users, to suit their needs. Sufficient and suitable bathing facilities must be provided to meet the needs of the service users. Repair or replacement of wooden commode chairs used by service users, that are no longer sealed with varnish to protect them from bacterial infection must be arranged and completed. Staff working in the care home must be in such numbers, which are appropriate for the health & welfare of service users. Staff must receive training appropriate to the work they are to perform. Effective quality monitoring systems must be implemented in the home to ensure satisfactory service delivery is maintained. Previous timescale: 30/03/06 30/11/06 30/11/06 30/11/06 30/09/06 31/10/06 30/11/06 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. 2. 3. 4. Refer to Standard OP1 OP14 OP15 OP15 Good Practice Recommendations Keep under review and where appropriate revise the statement of purpose and the service user guide. Purchases made on behalf of service users should be made in consultation with them or their representative. A menu to suit the capacities of all the service users should be provided to enable the service users to make a decision. A seasonal variation or option to the choice of meals DS0000032878.V304332.R01.S.doc Version 5.2 Page 25 The Mount Elderly Persons Home 5. 6. 7. 8. 9. OP20 OP26 OP35 OP38 OP38 10. 11. OP38 OP38 provided should be offered to ensure a varied & appealing diet for service users. Outdoor space for service users should be accessible and meet the needs of all service users, including those with physical, sensory and cognitive impairments. The premises should be hygienic and free from offensive odours throughout, including the activities room. When the money of each individual service user is handled, an appropriate record and receipt of the transaction should be kept. Safe food hygiene practices within the home must be maintained at all times. A risk assessment identifying power failure within the home must be completed. This should identify contingency plans for facilities and services effected which are not supplied by the homes’ generator. Suitable arrangements must be made for staff to receive fire prevention training. Risk assessments should clearly identify the significant findings and level of risk. The Mount Elderly Persons Home DS0000032878.V304332.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. 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