Inspection on 30/08/05 for The Mount Elderly Persons Home

This inspection was carried out on 30th August 2005.

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 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 03/08/06

The Mount Elderly Persons Home 31/01/06

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 136 Tennyson Road Luton Bedfordshire LU1 3RP Lead Inspector Andrea James Unannounced 30 August 2005 9:30 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 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 I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Mount Elderly Persons Home Address 136 Tennyson Road Luton Bedfordshire LU1 3RP 01582 723944 01582 723944 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Luton Borough Council Mrs Susan Stevens Care Home Only 39 Category(ies) of Older People (OP) 40 registration, with number Dementia over 65 (DE(E)) 40 of places Physical Disability over 65 (PD(E)) 40 The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10.2.05 Brief Description of the Service: The home is situated on the outskirts of Luton, but still not too far from the city 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. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection carried out 6 months after the last inspection. The manager was available for the duration of the inspection, which lasted for 5 hours. The inspection was carried out on the 30th of August 2005. The inspection process followed a case tracking methodology where samples of the service users files were selected at random, in order to be inspected. The inspector was able to speak to relatives, visitors, care staff, service users and the manager whose views are reflected in the main body of the report. What the service does well: The home provided care for 39 service users with varied degrees of dementiatype illnesses and manages to offer a satisfactory standard of care. The 24 care staff employed by the home were caring and those spoken to demonstrated a good understanding of the needs of the service users. The service users spoken to said they liked the home, the staff were good to them and they had a good life. Service users also expressed their delight in the quality of food they received and described the food as`” excellent”. Relatives and staff also spoke positively about the quality of the meals provided, saying it was “tasty” and the service users always seem to have enjoyed their meals. Relatives said they were happy with the care provided by the home and found the manager approachable and easy to talk to. Care staff were observed to treat relatives and service users with warmth and friendliness. Positive interactions were observed between relatives and the care staff on the day of the inspection. Relatives said they liked the home because it was “ homely” and not regimented. Care staff said the manager was supportive and their was a good sense of team work among the staff team. The home ensured that the service users received regular meetings and their views were acted upon in various ways. The records examined suggested that the care staff received regular supervisions and all staff expressed that the standard of training provided was high. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The home had 11 service users with high needs and the care staff spoken to said because of the needs of these service users more staffing hours were required. It was identified through assessments that these service users had nursing needs. The staffing levels at the home were not sufficient to meet the needs of the service users during the day and at nights. On the day of the inspection 50 of the care staff were agency staff. The staff spoken to said some service users needs were not met because they had to prioritise the needs of the service users. The home had made improvements to the level of activities to some service users but further development was needed to ensure those service users that had no stimulation was provided with a better activity programme. The home had 3 qualified First Aid care workers and as a result all shifts did not always have a qualified First Aider. This could mean the service users safety would be compromised if there were an emergency. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 7 Staff needed to offer better support to service users who were unable to feed themselves at meal times. The commission would like to thank the service users, relatives, care staff, ancillary staff and the manager for their co-operation during the inspection process. 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 I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 and 5 The home ensured that satisfactory processes to enable service users and their relatives to be able to choose the suitability of the home were available. This resulted in positive outcomes for the service users whose needs were assessed prior to admission and on admission. EVIDENCE: The home had satisfactory statement of purpose and had made further developments to the service users’ guide. The service user’s guide was recently printed in a professional leaflet and made available to service users and external agencies. The contractual agreements were also developed to include the cost of the placement for all service users. The home ensured that a pre- admission and admission assessment were carried out on all new service users to ensure their needs were identified satisfactorily. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 10 Relatives said they were able to view the home prior to admission and felt that they received satisfactory reassurances that the home could meet their needs. Records inspected showed that service users received a 6 weekly review to determine the permanency of their placement. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, and 11. The home’s ability to identify the health care, personal and social needs of the service users through care planning was good which resulted in good care practices for the service users. EVIDENCE: The care planning procedures in the home had developed since the last inspection. The care plan documentations inspected had full assessment of needs carried out on all the care plans inspected with a comprehensive care plan intervention on all needs identified from the assessment tools. The documentation also had current risk assessments, night care plans, 6 weekly review meetings and the wishes of the service users in the event of their death. There was a need, however, to ensure all care plans are reviewed on a monthly basis. The medication stocks, recording and administration were inspected and all found to be satisfactorily maintained. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 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 standard(s) 12,13 and 15. Most of the service users appeared to have a limited choice of activities due to the nature of the client group but improvements were noted to be given to enhance the social interactions of some service users. The home encouraged family contact and the meals provided were satisfactory to meet the various dietary requirements. This resulted in positive experiences for the service users. EVIDENCE: The service users were provided with some activities that helped to provide a fulfilled life style, however their was a lack of choice of activities and the programme implemented was not always adhered to due to the lack of allocated staff to carry out these activities. The manager said she had recently employed an activities coordinator but was still waiting for satisfactory clearances. Staff were seen to actively encourage individual service users to participate in activities but this was with the minority, the majority of the service users were seen to have very little stimulation apart from the television and staff interaction. Family contact from relatives to the service users were encouraged within the home and relatives spoken to said they were always made to feel welcome. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 13 One relative was seen to be taking her husband out for a walk to enjoy the summer’s day. The meals provided for the service users were varied and offered choice. Weekly menus were on display and the catering staff explained the dietary needs of the service users, which demonstrated a good understanding of the service users dietary needs. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 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 standard(s) 16and 18 Satisfactory complaints and abuse awareness processes were implemented in the home, which ensured service users were safeguarded from abuse and their concerns would be dealt with in a professional manner. EVIDENCE: The home had corporate complaints procedures, which were advertised in a satisfactory manner. Relatives and service users said they were aware of the complaints procedures but did not feel they needed to use it because the manager and care staff were always available if they had any concerns. The home had not received any complaints since the last inspection. The home ensured the majority of the care staff were trained in abuse awareness and good processes were in place to deal with any suspected abuse. The care staff spoken to said that received Protection of Vulnerable Adults (POVA) training. The home had a current POVA allegation that was in the process of investigation. The home followed the correct procedures to include disciplinary action where necessary. The commission was also informed of the allegation in writing. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19,21,22,23,24,25 and 26. The majority of the environmental standards in the home were satisfactory and as a result service users were enabled to live in a clean, safe and comfortable environment that suited their individual needs. However, offensive odours were identified in some areas of the home, which reflected negatively for service users and visitors to the home. EVIDENCE: Since the last inspection the home had made changes that further improved the environmental standards. The front of the building including doors and windows had received double-glazing. Three of the communal bathrooms had been refurbished to a modern standard and fitted with good lifting aids to maximise service users independence. The home ensured satisfactory standards of hygiene were observed in most areas of the home. The home’s domestic staffing levels were short on the day of the inspection due to sickness and as a result the care staff had to assist the domestic staff on duty to ensure hygiene standards were maintained. Offensive The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 16 odours were identified in a communal area of the home, which reflected negatively on the hygienic standards of the home. The manager was aware of this reoccurring problem. Several bedrooms had been decorated since the last inspection. The manager spoke of further plans forecasted for the future where the home was due to have the communal areas redecorated. The service users bedrooms were decorated to meet their needs. Service users and relatives said the bedrooms were satisfactory and they were able to bring in individual personal items. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,29 and 30 The processes for recruiting and training the staff team were good but the staffing levels in the home were poor, as a result the service users needs were not satisfactorily met. EVIDENCE: The home had satisfactory procedures in place for recruiting. The records checked showed that the procedures used by the home met the requirement of the regulations. The care staff appeared competent and dedicated to meeting the needs of the service users. The home had insufficient numbers of staff to meet the need of the service users. On the day of the inspection the home should have 7 carers but only had 6 and 50 of the staff team consisted of agency workers. The domestic staffing levels were also insufficient. The care staff spoken to said they worked very hard to provide satisfactory standards of care to the service users but felt that with the high needs of about 10-15 service users they were not able to meet all the needs. They said “ we are not able to work as a mainstream home “ we are more like a nursing home, because the service user are very frail and dependent”. This is having a knock on effect on staff moral both during the day and at night. One night staff said the workload is very heavy during the night for 3 carers to manage, they The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 18 have to put between 15 –20 service users to bed and some nights they do not get a break. Training records seen suggested that care staff received regular training in mandatory courses and those required to for the changing needs of the service users. Training undertaken since the last inspection included dementia awareness, abuse awareness and medication. 16 of the 25 care staff had obtained their NVQ level 2 qualification in care and future training was planned for nutrition and diabetes awareness. There was a need for a larger number of care staff to be trained in First Aid to ensure a qualified First Aider is on shift at all times. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36 and 38 The manager of the home created a positive image where relatives, service users and staff were able to communicate in an effective manner. EVIDENCE: The manager had several years experience in care and appeared knowledgeable about the needs of the service users. The records inspected showed that staff received regular supervision and staff meetings were held on a regular basis. The manager operated an open door policy. Relatives said they found the manager approachable. The home had corporate health and safety policies, and procedures to ensure service users safety were implemented. All fire records seen were satisfactorily maintained. There was a need to review the fire risk assessment, which was The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 20 outdated by 2 years. The call systems in the home were tested and found to be satisfactory. The home ensured that regular water temperatures were recorded and external contractors were used to ensure the home was free from legionella. The home was locked at all times to maintain the safety of the service users, as a result the service users movements were restricted within the home. Care staff felt that the service users would benefit from having a conservatory built to ensure they had the benefit of natural light. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x 3 3 3 The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? 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 12 Regulation 16 (2) (m) (n) Timescale for action Arrangements must be made to original ensure all service users receive date:30.11 satisfactory stimulation and .04/30.3.0 motivation in the home. 5. new date:30.10 .05 Arrangements must be made to Original eradicate all offensive odours in date: the identified areas of the home. 30.3.05 New date:30.10 .05 Sufficient numbers of staff must Original be made available at all times to date: meet the needs of the service 30.03.05 users. The minimum must be a New ratio of 6:1 date:30.10 .05 Arrangements must be made to 30.10.05 review the ratio of agency staff used on shift to ensure service users continuity of care is not compromised. Arrangements must be made to 30.10.05 re assess the needs of the service users with high needs and ensure the home is able to meet their needs. Requirement 2. 26 13 (3) 3. 27 18 (1) 4. 27 18 (1) (b) 5. 2 14 (2) (b) The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 23 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. Refer to Standard 7 38 27 Good Practice Recommendations Arrangements should be made to ensure all care plans are reviewed on a monthly basis. A review of the current fire risk assessment should be carried out. Sufficient ancillary staff should be available at all times to ensure the hygenic standards of the home are maintained. The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Bedford 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. Extracts may not be used or reproduced without the express permission of CSCI The mount I51 S32878 The Mount V242995 300805 Stage 4.doc Version 1.40 Page 25 - 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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