Inspection on 11/12/07 for The Mount Nursing Home

This inspection was carried out on 11th December 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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Hawkhills

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

CARE HOMES FOR OLDER PEOPLE The Mount Nursing Home 43 Lister Lane Bradford West Yorkshire BD2 4LP Lead Inspector Chris Levi Key Unannounced Inspection 11th December 2007 09:30 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 Nursing Home DS0000070136.V352287.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 Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Nursing Home Address 43 Lister Lane Bradford West Yorkshire BD2 4LP 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) 01274 641444 Holberry Care Ltd vacant post Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of care only: Care home with nursing - Code N; to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE The maximum number of service users who can be appointed is: 40 2. Date of last inspection Brief Description of the Service: The Mount Nursing Home is a converted Victorian property and is registered to provide personal and nursing care for a maximum of 40 people. The home has 3 double rooms, the remaining accommodation is provided in single rooms two of which have en-suite facilities. A passenger lift provides access to all areas of the home. Communal space is provided on the ground floor and consists of two lounges and a dining room. The home is located in a residential area and overlooks Peel Park; there are a number of small shops nearby. The home is set in mature gardens and ample car parking is provided on site. The current weekly fees charged by the provider are £343.98- £550. Additional charges are made for hairdressing, private chiropody and trips out, and newspapers. This information was provided to the Commission for Social Care Inspection in December 2007. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection by the Commission for Social Care Inspection since the home was bought by Holberry Care Ltd in August 2007. The providers are now registered to admit older people and older people with dementia. Information about the home requested by the Commission for Social Care Inspection included a new document, the Annual Quality Assurance Assessment (AQAA) which was completed by the home manager and returned to the CSCI. This enabled the inspector to analyse information that included the number of reported accidents, complaints and compliments from residents and relatives and other relevant information to help plan for the visit to the home. It also provided opportunities to demonstrate how the home could improve its services to the people who live at the home. The providers were not notified of this inspection in advance. This enabled the inspectors to observe how the home is run on a day-to-day basis, without any changes being made to the usual routines of residents and staff. The visit started at 9.30 am and finished at 5.30pm. The person in charge of the home was the Manager, Mr D Holt. As the home provides care for people with dementia, two inspectors visited the home. During this inspection we used a new tool called the Short Observational Framework for inspectors or SOFI. This is a framework for understanding and recording the levels of staff engagement and activity at the home. It gives an insight into the wellbeing and quality of care experienced by people who live at the home. One inspector carried out this observation and recorded what she saw for 1hour 50 minutes. The SOFI observation was used alongside other ways of getting evidence about the quality of care. The other inspector spent time talking to residents, relatives, and staff, to find out what it is like to live, work and visit The Mount. A number of documents were reviewed relating to residents, staff and health and safety. Twenty residents and relative survey forms, plus ten staff surveys were sent to the home before the visit to enable them to provide the Inspector with opinions about standards at the home. 14 resident/relative surveys were returned. The response was mixed. 9 responses were positive. Comments included “ a much improved environment.” “When I visit I am always updated about how my mum is doing.” The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 6 Five surveys gave negative feedback about the service. Comments included “the food is not as good.” “Sometimes the residents have to wait to go to the toilet because staff are dealing with EMI residents.” Staff comments were mixed and mentioned lack of training to care for people with dementia. One survey was received from an external health professional who visits the home. The comments were positive and included, “The staff appear to have a good knowledge of mental health issues.” Mr Holt and Mr Berry the owner of the home were given feedback about the findings of the inspection at the end of the visit. What the service does well: What has improved since the last inspection? What they could do better: The home has introduced a new system to record the needs of residents. Most of the information is held on a computer and there are paper copies of some information. Whilst this is detailed, there was a lack of a person centred approach in the information held. Generally, there was evidence that identified a resident’s needs but no information for staff as to how those needs should be met. This could lead to an inconsistent approach by staff when providing support to residents. An example seen identified, a resident’s social needs, but did not identify how this should be done. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 7 The documentation for a resident with low weight, who was feeling generally unwell, should have had more detail about what staff must do to assist him, until results from medical examinations were available. The manager should ensure residents with infections who are cared for in their own rooms are not socially isolated, as this may have a negative impact on their wellbeing. More consideration should be given to ensure the home meets the cultural and dietary needs of individual residents. One resident who has lived at the home for sometime, has become more frail and his physical abilities for self care did not reflect the information held in the plan of care. Where residents share a room the home must ensure their dignity and privacy is not compromised. It is recommended that daily social activities be more suitable for people with dementia. Some people were enjoying the television and music playing on the day. However, the noise level from this was high, and may have a negative impact on residents who were not involved. The introduction of a large clock would help residents orientate to the time of day. As the printed menus are very small print, a large menu board displayed in the home would help to remind residents what food was on offer that day. Generally, staff recruitment is satisfactory. However, where gaps are identified in an application form they should be explored to ensure new staff are suitable to work with vulnerable adults. The home manager must ensure staff undertake an induction programme which complies with the Skills for Care, Common Induction programme. Also all staff must undertake training in Infection Control, and Safeguarding Adults from Abuse to ensure they are competent to care for people living at The Mount. 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 Nursing Home DS0000070136.V352287.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 Nursing Home DS0000070136.V352287.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): Standards 1 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is written information about the home to help people decide if they wish to live there. The needs of prospective residents are adequately assessed to ensure staff can meet their individual needs. EVIDENCE: The home has an up to date statement of purpose. This document provides information to prospective residents or their families about the services provided by staff at The Mount. There was evidence in two plans of care that staff assess the needs of people before they move to the home. This provides staff with opportunities to The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 10 develop effective plans of support in preparation for the person as they move into the home. One relative said, “ I looked around a few homes and this one was the best.” The Mount Nursing Home DS0000070136.V352287.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): Standards 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ care plans need to be further developed to ensure staff know how to consistently meet the individuals needs. The dignity and privacy of residents is not always maintained. EVIDENCE: The documentation for three residents was looked at in detail. This was to establish if the written plans of care produced by nurses, provides clear information about the care needs of the individual. In two of the plans there was evidence, on a computerised system (some of which was also in paper copy) of significant detail about individual support and nursing needs once they moved to the home. There was information about visits from an external health professional, when nurses at the home decided they needed specialist support for the resident’s ongoing well-being. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 12 Risks to residents were identified and actions to reduce the risks were in place. The shortfall with the plans is, that they do not identify how staff should undertake to provide support to individual residents. This could lead to an inconsistent approach by staff when providing support to residents. An example seen identified a resident’s social needs should be met, but did not identify how this should be done. The introduction of a person centred approach to gathering relevant information about residents lives before they move to the home will provide staff with the opportunity to deliver a more individualised approach to the support they give to residents. The documentation for a resident with low weight, who was feeling generally unwell, should have had more detail about what staff must do to assist him, until results from medical examinations were available. The third care plan we looked at did not give a clear picture of the person’s likes and dislikes in relation to food and activities of daily living. There was insufficient detail on their abilities and needs in relation to personal care. The person’s social cultural and religious needs had changed and were not identified. The records seen did show that the home had taken appropriate action in response to changes in weight and loss of appetite. It is acknowledged that the owners are undertaking to produce new plans of care for every resident and this is a time consuming task. However, information relating to individual residents must be up to date and relevant to enable staff to provide appropriate levels of care and support. Medicines are stored safely, and checked to ensure they are correct when they arrive from the pharmacist. This reduces the risk of a resident’s medication being incorrect. The nurse administering medication had recently qualified and was competent to undertake this task. The medicine trolley should be fastened to the wall when not in use, to ensure it cannot be removed inappropriately. Observations throughout the day indicated that staff do not always consider a residents dignity when undertaking care/nursing tasks. Two incidents were noted where residents dignity and privacy was compromised. These were discussed with the owner and manager. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents at the home can generally spend their day as they choose, seeing whom they choose, when they choose, but for many their levels of frailty restrict some choices. Improving social stimulation for residents with dementia may improve their well-being and quality of life. EVIDENCE: Visitors are welcomed into the home. One said, “they always keep me informed about mums condition and telephone if there is any accidents.” Comments from residents were mixed. The majority of those who spoke to us said they were happy at the home and felt well looked after. A couple of residents said the food was not as good as it had been in the past. During the observation in the lounge we saw some good examples of staff engaging with people. One staff member told a person that it was nearly Christmas. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 14 The levels of staff engagement were limited even after staff were prompted by the senior carer and owner. At the end of the observation the owner and the manager were in the lounge talking to people. Staff interaction tended to be task orientated such as giving of drinks, assisting with medication, assisting with transfers. People who were able to respond verbally got more attention from staff. Two people who liked walking were asked to sit down without being offered alternative ways to occupy their time. Two out of the 6 people observed, engaged with the activity of watching television but they lost interest when the sound was drowned out by the film playing in the adjacent lounge. Others remained in a passive or withdrawn state throughout the observation. It is recommended that daily social activities be more suitable for people with dementia. Some people were enjoying the television and music playing on the day. However, the noise level from this was high, and may have a negative impact on residents who were not involved. The introduction of a large clock would help residents orientate to the time of day. The likes, dislikes, and social needs of people are not identified and there are no clear plans recording how these needs are met. In one case the home had recorded that one person liked to visit a place of worship with family assistance. The family are no longer able to assist but the home had not recorded how this need would be met. The Chef who is new in post, said that snacks such as soup, biscuits and bread for sandwiches are available for people during the evening and night. We saw records showing that fridge and freezer checks are carried out on weekdays. The chef has sought guidance on meeting the dietary requirements of a person with diabetes and they use full fat milk, cream etc to fortify meals Choice is offered at the table, however more information is needed on individual likes dislikes and preferences. Menus are on dining room tables. However, the printing is very small and difficult to read. It was recommended that a large board be placed near the dining room and the chef write up the dishes of the day to remind residents what is available. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 15 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): Standard 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are provided with information about how to make a complaint. Staff are aware of the need to keep residents safe from abuse. EVIDENCE: The Mount has a poster displayed in the foyer advising people how to make a complaint. The manager stated that one complaint had been received which required investigation and a response to the complainant. The manager must ensure this complaint is recorded. Relatives said they felt confident that any concern they raised would be dealt with appropriately. In discussion with some staff, they said they had not received training relating to Safeguarding adults from abuse. In conversation they said they would report any concerns to the manager. However all staff need to be trained to The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 16 understand, and recognise different types of abuse, to enable them to protect residents in their care. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 17 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): Standards 19, 20, 21, 23 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate accommodation for service users, and facilities for staff who work in the building. EVIDENCE: The new owners have changed the type of residents who live at The Mount. Most new residents have dementia and existing environmental standards are not ideal for this type of client. There is limited communal space for residents to move about in and this may affect residents well being. That said, in the three months since the new owner took over there is evidence of significant investment and improvements in the fixtures and fittings at the home. To provide a safer environment key-pads have been fitted to a number of corridor doors, to minimise the risk of residents getting lost or injuring The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 18 themselves in the maze of corridors. The corridors are now much brighter and there is signage to assist residents find the toilets, enabling them to maintain their independence. New chairs and beds have been bought, again these are suitable for residents living at the home. A safe enclosed garden area has been created for residents to spend time outside. The bathrooms remain in a poor state of repair. They are very institutionalised and need to be personalised to make bathing a positive experience for residents. All the toilets looked at, had locks that worked, thus providing privacy for users. There was a rope barrier across the bottom of the stairs and managers told us this was to prevent people falling on the stairs when using them unsupervised, The carpet in the home has a heavy floral design and although this is in good condition, it does not reflect best practice in dementia care. The owner stated a more appropriate carpet was due to be fitted the following day. A programme of refurbishment will continue as identified by the owners. In one bedroom visited, there was appropriate flooring, but no lockable drawer to allow a resident or their relative to store things securely. A double room had no privacy curtain to divide off the two beds, compromising the residents’ privacy and dignity. There are two bedrooms that can be accessed through another resident’s bedroom. This door was locked to maintain privacy but a sign indicated it was a fire escape route. Locking the door may compromise resident safety in the event of a fire. The home was clean and tidy and free from odour. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 19 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): Standards 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. The recruitment of staff is thorough to protect people living in the home. However new staff would benefit from a more detailed induction programme to ensure they can meet the needs of residents. EVIDENCE: The numbers and skills mix of staff on duty at the time of the visit was satisfactory to meet the needs of the 30 residents in the home. The rotas indicated that there are no domestic or laundry personnel on duty at the weekend. If care staff have to undertake these tasks at the weekend, it reduces the time they have to spend with residents, and, may impact on the quality of care they receive. The manager stated they were planning to recruit weekend workers to these posts. The recruitment files of two new members of staff were looked at. Both had relevant information in place to ensure they were suitable to work with vulnerable adults. It was recommended that, where gaps are identified in an application form, they should be explored to ensure new staff are suitable to work with vulnerable adults. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 20 The home manager must ensure staff undertake an induction programme that complies with the Skills for Care, Common Induction programme. Also all staff must undertake training in Infection Control, and Safeguarding Adults from Abuse to ensure they are competent to care for people living at The Mount. In discussion with two members of staff they said they had not received this training. It is positive to note that information provided to the inspector indicates that 14 of the 24 care staff have achieved NVQ level 2 and the remaining 10 are working towards the award. Other training provided for staff included dementia care, and care of the dying. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 21 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): Standards 31, 32, 33, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management aim to promote the wellbeing of people living and working at the home. Further improvements in recordkeeping, staff training, and the environment would benefit both residents and staff. EVIDENCE: Mr D Holt is the new manager at The Mount. He has been in post for 5 months and previously worked at another home owned by Holberry Care Ltd. Mr Holt is a registered nurse and has experience of working with older people. He has a formal management qualification, but is yet to register with the CSCI as Registered Manager of The Mount. His registration will mean that people The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 22 who live at the home can be more confident that their home is managed by a trained an qualified person. Residents, relatives and some staff said, Mr Holt was approachable and keen to involve residents and relatives with information about what happens in the home. Some staff said they did not feel valued and would not discuss their concerns with the management team. As the home is only four months into new ownership, evidence of an annual quality review was not available. The owner provided anecdotal evidence of achieving quality standards from Bradford Social Services, and said he plans to set up a relatives support group where standards in the home would be discussed. A representative of Holberry Care ltd is required to undertake monthly unannounced visits to The Mount, resulting in a written report-- Regulation 26 visit reports. The Inspector would appreciate copies of these reports, as it helps to inform the inspection process. To date only two members of staff have received one to one supervision to discuss their competence and personal development. More senior staff need to be trained to become effective supervisors, to enable all staff to benefit from supervision four times a year. There has been only one staff meeting in August 07.No minutes were available. One health and safety hazard was noted during the visit. A bed rail sticking out from the bottom of the bed could cause an ankle injury to staff or resident. Staff confirmed they had received moving and handling training in the past year. No one was able to confirm they had received Infection Control training. The fire safety maintenance person was at the home checking and refilling fire extinguishers. Various Health and safety and maintained documents were made available for the visit. However, due to time constraints they were not looked at during this visit. The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 23 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 3 x 3 x x n/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 2 2 x x 2 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 2 2 3 x x 2 x 3 The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP10 Regulation 12 Requirement Staff must ensure the privacy and dignity of residents at all times. ( Bedrooms that are shared should have curtains or other means of ensuring privacy?) Care plans must show how staff are to provide care and support to residents. That information in them is up to date to meet the changing needs of individual residents. They must demonstrate that residents cultural and dietary needs have been addressed. Staff must undertake an induction programme that complies with the Skills for Care, Common Induction programme. Also all staff must undertake training in Infection Control, and Safeguarding Adults from Abuse to ensure they are competent to care for people living at The Mount. The manager Mr D Holt must register with the CSCI as registered manager of The Mount. DS0000070136.V352287.R01.S.doc Timescale for action 30/01/08 2 OP7 15 28/02/08 3 OP30 OP18 18 30/03/08 4 OP31 8 28/02/08 The Mount Nursing Home Version 5.2 Page 25 5 OP10 12 The manager must ensure residents with infections who are cared for in their own rooms are not socially isolated, as this may have a negative impact on their wellbeing. 30/01/08 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 OP31 OP12 OP15 Good Practice Recommendations The owners undertaking monthly regulation 26 visits may consider sending these reports to the CSCI inspector. Social activities may be more specific to meet the needs of residents with dementia. A clock in the lounges should help people with dementia orientate to the time of day. To help residents identify what food is being prepared, the home may consider introducing a “food of the day board” situated near the dining room. Individual likes dislikes and preferences should be identified and taken into account. Staff may benefit from regular staff meetings to provide opportunities for the management team to hear their views about working at the home. All staff should be offered supervision four times a year The bathrooms remain in a poor state of repair. They are very institutionalised and need to be personalised to make bathing a positive experience for residents In one bedroom visited, there was appropriate flooring, but no lockable drawer to allow a resident or their relative to store things securely. Consideration might be given to increase communal space, to provide more freedom of movement for residents with dementia. 4 5 6 7 8 OP32 OP36 OP21 OP24 OP20 The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 The Mount Nursing Home DS0000070136.V352287.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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