Inspection on 12/12/06 for The Mountain Ash

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

The Mountain Ash 17/01/06

The Mountain Ash 13/08/05

The Mountain Ash 05/01/05

The Mountain Ash 10/08/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 The Mountain Ash Fairlight Gardens Fairlight Cove East Sussex TN35 4AY Lead Inspector Jason Denny Key Unannounced Inspection 12th December 2006 2:30pm The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Mountain Ash DS0000021252.V322269.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mountain Ash Address Fairlight Gardens Fairlight Cove East Sussex TN35 4AY 01424 812190 01424 814500 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) Cove Care (Mountain Ash Residential Home) Limited Mrs Julie Dignum Care Home 11 Category(ies) of Learning disability (11), Physical disability (11) registration, with number of places The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users must be aged between eighteen (18) and sixty-five (65) years on admission. The maximum number of service users to be accommodated is eleven (11) Service users with a learning disability or learning and physical disability only to be accommodated 17th January 2006 Date of last inspection Brief Description of the Service: The Mountain Ash provides care and accommodation to eleven adults with a severe learning disability. The majority of service users also have a physical disability. The Registered providers are Cove Care (Mountain Ash Residential Home) Ltd. This company was purchased by Minster pathways late in 2005. Minster pathways also purchased a company called Evesleigh ltd in 2006. Cove care ltd is currently overseen and links in with the company called Evesleigh care group, which manages other homes in the area on behalf of Minster Pathways. The home is a converted hotel situated in the village of Fairlight. Ore, on the outskirts of Hastings, with shops, amenities and railway station, approximately three miles away. All accommodation is at ground floor level; bedroom accommodation consists of eleven single rooms. Communal accommodation comprises of two lounges and a dining room. Other facilities include two relaxation [sensory] rooms, an indoor swimming pool and gardens. The home has two minibuses. There are currently no vacancies and have not been for several years. Information on the range of fees charged is within the homes current statement of purpose/service user guide and currently ranges from £877 to £1290 per week. Service users [Residents] are additionally charged for personal items such as toiletries, holidays, hairdressing additional outings such as the theatre and clothes, and additional pub and restaurant meals. Inspection reports are not routinely sent out to families and advocates after each publication although a copy is kept on display in the reception area of the home and can be obtained via the manager. A service user guide containing the most recent inspection report is sent to any interested person [or their representatives] looking to move into the home. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced key Inspection, which included a visit to the home which took place between 2.30pm and 7.30 pm on December 12, 2006. The inspection focused on the key major areas such as how needs are being met, activities, lifestyles, environment staffing of the home, along with how the home is managed, and how concerns are dealt with. During this inspection process, which covers the period since the last inspection January 17, 2006 and the week of the home visit, all social workers involved with the home have been spoken with. 4 relatives returned survey comment cards on behalf of Residents which along with social services Confirmed this is a excellent home especially with regard to the care 10 of the 11 Residents were observed or spoken with during the inspection, which relied upon staff to support with communication. How staff interact with and support Residents to make choices was observed. Staff on duty were spoken with during the inspection with reference to their training and how they are supported to carry out their roles to the highest standard 4 of the Residents care-planning records was looked at in detail along with how all their needs are met. Diversity and equality areas were explored in relation to lifestyles. Discussions with management looked at progress since the last inspection. The inspector toured all communal areas of the home and some bedrooms. Meal arrangements were examined. A record of complaints was inspected. Staffing was looked at in detail along with the homes management, including measures to ensure quality for Residents. Four [4] outcome areas are assessed as Excellent, and the other four [4] areas are assessed as Good overall. What the service does well: Excellent care is provided by the service for all. This was evident from observations during the inspection of both Resident’s and staff, looking at records, speaking with the manager and feedback from relatives and Social Services who fund the Residents. One relative stated in their questionnaire sent to them by the Commission “choosing this home is one of the best decisions I have ever made” There have been no new Residents since 2001; The home continues not to have vacancies due to the high standards of care. The excellent standards in the home are based on an attentive and knowledgeable manager and a staff team, which has remained largely unchanged for many years. The staff team are highly skilled and motivated and are always in sufficient numbers to ensure that all Residents received high amount of attention. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 6 Residents in the home have a severe learning disability and most lack any verbal skills or are able to understand sign language and other communication techniques. Despite this the home has worked hard to understand the needs and preferences of all Residents. Good two-way communication was observed during the inspection based on giving Residents as much choice and freedom as possible. Residents benefit from an exceptionally clean, spacious, and well equipped environment fully suited to their needs where most Residents have physical disabilities. Residents benefit from having a high range of activities in the community and also within the home such as two sensory/relaxation rooms and a indoor swimming pool. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, & 3 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The information in the homes guide is less clear following a rewrite since the last Inspection with minor work needed to make it more specific to the home. Prospective new Residents are carefully assessed before moving in with existing Residents under regular and effective ongoing assessment to ensure their needs continue to be met with all compatible with each other. EVIDENCE: The home’s Statement of Purpose contained within Resident’s [service user] guide to the home and organisation was inspected in the manager’s office. The Statement of Purpose and guide is not displayed for Residents for as the manager explained this has no meaning for them and that it would be token gesture to reproduce the guide on tape or in sign language or other communication forms. Residents have a very severe learning disability as confirmed in records and observations and rely on staff to understand their body language with some able through limited verbal skills or pointing to make their choices and views know. Advocates for the Residents who read the Statement of Purpose and guide [usually relatives] are therefore encouraged to play a key role in the running of the home on behalf of Residents. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 9 The guide and Statement of Purpose would be sent out to any prospective new Residents although the home has not had a new Resident since 2001 and continues to operate with no vacancies. The manager stated and showed in written evidence that although Residents have severe communication difficulties she has made a referral for 3 to have a Speech and Language assessment to establish whether there would be any value in developing some communication aids. The social workers for all Residents indicted that all current needs are being met helped by the home’s continued focus as a specialised home for those with physical and severe learning disabilities. The home’s Statement of Purpose was updated in October 2006. Two Main errors were found although only a recommendation was made, as this was not affecting outcomes. Details relating to the company ownership were found to need clarifying as the registered provider is still Cove Care ltd although the ownership has changed over the last year and the home is overseen by Evesleigh Care ltd. More significant is the potential confusion caused by the homes range of needs to be met being different for the admissions policy and procedure, which stated that the company welcomes referral for those with a mild to moderate learning disabilities. The manager agreed that the admissions policy needs to be specific to Mountain Ash and its statement on the range of needs it meets both in practice and as stated in the Statement of Purpose. Following the inspection the Commission was sent a new revised Statement of Purpose dated December 12, 2006, which had correct company details. However this document had the admissions policy deleted from page 4 with a separate policy attached, which was general and not specific to the home. A specific admission policy needs to written into the Statement of Purpose to prevent any confusion although this is not affecting outcomes with the manager having good assessment skills and no one having moved in since 2001. The range of learning disability the service meets which in practice is the severe type should be stated.A further version of the Statement of Purpose was received on January 5, 2007 resolving all previous issues. The home has not admitted any new Resident since 2001 and pre –assessment information has previously been inspected. The manager was found to be reassessing all Residents to bring these records up to date and to ensure that all needs are being met and whether any additional support is needed. This was evident in the case of one Resident whose behaviours have changed recently causing a potential risk to others .A full re-assessment has taken place including medication with good and proactive management such as changing mini bus seating positions was seen to be stabilising this situation in the best interests of all Residents. This Resident was observed to interact well with staff and respect other Residents with no issues noted. It was evident from feedback to the Inspector from social workers, relatives, and other visitors to the home, along with the inspector’s observations [not The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 10 possible to get clear verbal feedback from Residents] that all Residents are currently getting their needs met to an excellent standard. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Care-Plans contain good information in line with the attentive and skilled care given. The plans will benefit from a stated general aim or goal although this is not affecting outcomes. All Residents have a advocate who speaks on their behalf Sensible, full, and positive risk assessing takes place EVIDENCE: Four of the eleven care-plans were looked at in some detail. All of the care-plans looked at were found to be up to date and well presented and sufficiently detailed showing the full range of areas to be aware off. Each of the care plans fully linked to the original assessment carried out when each Resident moved into the home. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 12 Clear evidence was seen of how Residents care and health had improved since moving into the home such as in the area of skin care where some Residents had serous issues when they moved in which they do not experience now due to improved care. Much of the focus is on maintaining the current quality of life for each Resident and ensure they remain comfortable and can have an active lifestyle. The manager explained how none of the Residents due to the severity of their learning disability and some physical disability were being supported to have independence goals as they is not realistic. The manager did explain how each Resident has current aims / key issues to be aware of. The home was therefore advised to clearly identify this as aim or gaol within the care plan so that all are aware of this so that success can be measured against it. One particular Resident is receiving an increase in support due to some recent behaviours to ensure that she can continue to live in the home and not pose a risk to others. This could therefore be written up as aim. Following the inspection the manager sent the Commission a written statement of aims for each Resident which are currently being followed. The key worker together with the manager and the Resident’s advocate carries out care planning. Each Resident has an advocate who speaks on behalf of their Resident as they lack the skills to fully do this themselves. Residents also benefit from knowledgeable staff all of whom sign the care-plans as seen in records and discuss the needs of Residents at regular meetings and who are closely supervised. The inspector observed the attentive and clear way Residents were supported during the Inspection. Written records showed that each Residents has a range of detailed and specific risk assessments subject to review such as in the case of one Resident who now sits in a different position in the house vehicle following an incident. The social worker/care manager who funds all Residents stated that the care in the home is “excellent” a point confirmed by relatives who sent questionnaire surveys to the Commission or spoke with the inspector. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16, & 17. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. There is exceptional arrangements in place to ensure that residents participate in a wide range of activities. Residents enjoy space, flexible routines and good attention as to their preferences. Meals are good. EVIDENCE: As at the last inspection lifestyle arrangements remain the same in that five residents attend external day centres and there is a detailed programme of activities in place for the six residents who remain at Mountain Ash. Staff spoken with advised that there are regular trips to the neighbouring towns of Rye, Hastings and Battle. Residents enjoy shopping, bowling, pubs and The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 14 cinema and theatre. On the day of the Inspection two Residents were observed returning from a Christmnas theatre trip with this planned for others One of the residents is taken to church on Sundays. Routines are relaxed as well as structured and flexible depending on preferences and needs. At the time of inspection there was a music session in the main lounge, some residents had used the swimming pool, and two others had been freely enjoying the sensory rooms. The inspector purposely chose to visit on a Tuesday afternoon /evening as at most other times Residents are out of the home attending various day centres or other community settings. The manager advised that over the last two inspections that they have rearranged the rota so that they can provide more outings in the evenings. The company owns two mini-buses and they are used for all transport arrangements. Seven of the staff team can drive the minibuses. Residents enjoy an annual holiday. The home extends a warm and open welcome to visitors as confirmed in survey cards along with a clear and secure visitors policy. Resident’s benefit from a healthy and well-planned diet based around their health needs such as diabetes. A meal was observed being served which indicated a balanced and wholesome diet as evidenced also in menus. All Residents were observed to freely enter the dinning room for meals at items flexible to them. All received any necessary support such as help with eating, and benefited from good staffing levels. The atmosphere was relaxed and unhurried throughout. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, & 20. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Health needs of Residents are exceptionally well managed in their very best interests. EVIDENCE: Staff receive training that is relevant to meeting the physical needs of the residents accommodated. In relation to residents who have limited mobility, the regular use of the pool, Snoozelen rooms, relaxation chairs and standing frames all assist in ensuring good circulation, posture, comfort and prevention of pressure sores. Information is now included in one of the resident’s care records about the type and description of the seizures they experience. In relation to medication records, the home now records on the back of the recording chart if medication has been stopped or the dose altered. An inspection of medication stocks and records showed good practice with all ears in order with medication securely stored in a dedicated room. It was evident how the regular reviews of medication has had positive effect on one Resident who had experienced a recent change in behaviour. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 16 All aspects of the person’s mental health were found to be closely monitored in the best interests. It was observed and seen in the person’s active lifestyle that the person is not being heavily sedated in order to reduce behaviours. A senior staff person explained how all Residents have recently had full health checks. One Resident has been supported by the home to have more extensive dental examinations under anaesthetic resulting in positive outcomes. It was noted in 3 care plans looked at how their original pre assessment when transferring from another care service, how each had serious skin conditions which have not proved to be an issue in this home as confirmed in records. Residents’ weights are monitored regularly. Specialist advice and support is obtained when necessary to meet the individual needs of the residents accommodated. The home’s pharmacist has provided training for staff on diabetes. It was noted that since the last inspection a physiotherapist has visited the home and reviewed and updated advice regarding daily exercises carried out by one of the residents. In relation to one resident there was a detailed risk assessment in place in respect of what action to be taken should they suffer a seizure. . All staff have had training in moving and handling. The manager and deputy manager completed a course to become trainers in manual handling in 2004. They hope to update this training so that they can continue to provide training for their staff team. Some of the residents have very limited mobility so their position is changed regularly throughout the day. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, & 23. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Complaints or concerns about the service continue to be rare and Service Users are protected from harm. There continues to be no upheld complaints about the care in the home for many years. All staff are fully aware of how to best protect Residents welfare. EVIDENCE: The manager advised that there had been one complaint made to the home since the last inspection of the home. This complaint was found to be recorded in the complaints file but did not relate to care in the home but rather the alleged sound of car radio music in the outside car park when staff arrived for weekend shift. A study of the Complaint’s file showed no upheld complaints about the care in the home since records began. Residents’ finances were discussed in detail and inspected at the last Inspection and records held in relation to two residents’ finances were examined. Individual bankbooks clearly showed all incoming monies and the home kept detailed records of all expenditure. Receipts are kept for all purchases. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 18 All staff have had training in adult protection and prevention of abuse. Staff recently did refresher training entitled Protection of Vulnerable Persons training The home has a clear policy and procedure which all staff cover. This has also been revisited when all staff went through the new common induction standards. Staff spoken with indicated a clear and good understanding of how to identify potential abuse and report it. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, & 30. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from an exceptional environment in terms of space, facilities, suitability and cleanliness. EVIDENCE: The inspector toured the environment and looked in some bedrooms with Residents permission. Accommodation provided is spacious. Furniture and fittings are modern, homely and domestic in design. There are a variety of communal areas, which means that several different activities can be carried on at the same time. The swimming pool is a valuable resource and the resident’s benefit individually from regular access. Communal areas include a large lounge/dining room. In addition there is a second lounge and two snoozelen rooms. In the main lounge there is a television and music centre. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 20 Some of the residents have their own specialist relaxation chairs in the lounge. In the second lounge there is a piano and a music system. One of the staff spoken with stated that this lounge is often used by residents who enjoy quietness and if they want to be on their own as was observed during the Inspection. There is a large garden to the rear of the building including a large decked area. There is also an indoor swimming pool on site with hoist facilities and specialist changing areas. The swimming pool is available for hire by the wider community, outside of the times used by the residents of the home. Each of the residents has their own bedroom some have en-suite baths, and all rooms are spacious and have en-suite facilities. Residents have varying degrees of physical disabilities and there is a wide range of specialist equipment in place to meet their individual needs. Since the last inspection a number of Residents have purchased widescreen HD TVs which have been helpfully mounted on their walls. 10 of the 11 Residents were observed using the dinning room for their evening meal selecting their preferred positions and have sufficient space. All areas of the home, such as bedrooms, communal areas, and the kitchen/laundry seen were found to be exceptionally clean with no unpleasant odours. This was the more remarkable given that this was an unannounced Inspection and that most of the Residents have support with incontinence or changing pads. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, & 36. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Staff are well supported, supervised, exceptionally well trained and motivated, and well suited to meeting the complex needs of Residents. EVIDENCE: The manager advised that there are generally six care staff on duty, [never going below 5 and sometimes 7 depending on activities], not including the manager, through the day. The manager also helps on the care side on occasions such as seen during the mealtime on the inspection. The home continues to have low staff turnover rate with just two staff leaving within the last year to eighteen months. All staff spoken with on duty have worked in the home for a minimum of 5 years with such continuity benefiting relationships and understanding of Residents The manager again reported that home does not use bank or agency staff. If there are vacancies or sickness then part-time staff work overtime. It is company policy to wait until a CRB (criminal bureau check) is obtained prior to new staff starting to work in the home. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 22 12 of the 20 care staff have now achieved an National Vocational Qualification in Care at least National Vocational Qualification 2 with 2 due to finish. Some staff have National Vocational Qualification at level 3[senior level] and some [2] seniors/deputy have level 4 at management level. All staff were observed to be attentive positive, and communicated with Residents in an appropriate manner. Good team working was also observed under the clear and positive direction from the senior staff person in change of the shift. Recruitment files were not looked at as the manager advised that no new staff had started sine the last Inspection when files were last looked at where no issues were found. The manager advised that the new company were keen to continue investing in staff training. A training matrix showed that all staff had received core training in 2005 and 2006 this includes first Aid, Moving and handling, and fire safety. Staff have also had training on adult protection, epilepsy and diabetes. New common induction standards came out in September 2006 and the Inspector found that the manager has put all her staff through this as precautionary measure as noted in a random staff file looked at. This training was not compulsory for those staff who had done National Vocational Qualification or foundation training Records showed that all staff receive regular and written supervision on monthly basis which exceeds the national guidance of two-monthly. The staff team is divided into groups and members of the senior team take on the responsibility for supervising staff in their group. It was evident from observation and feedback from relatives and social services that all staff are clearly well supervised in the best interests of Residents. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, & 42 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is run well and the manager is continually looking at ways of updating her knowledge and skills, which in turn is of benefit to the home. This area will be assessed as excellent once the full and necessary management qualification is achieved. Residents are protected by living in a safe home Residents benefit from a quality service although clearer evidence is needed of future plans and how the organisation supports the home. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager has effectively managed the home for many years and has completed the Advanced Management in Care, which she confirmed is equivalent to NVQ level four. The manager has also done part of the Assessor’s Award. The remaining qualification is the registered manager’s award for the management component with the manager booked to commence this in January 2007. She and the deputy manger have attended a number of courses during the coming year including: - time management, assertiveness,, recruiting, managing change and developing care plans. Staff spoken with stated that they were well supported and that if they had a problem they would be able to speak with either the manager or deputy manager. Staff meetings are held once a month and team leader meetings are also held monthly. It was evident that the management of the home is highly competent, attentive and positive. The Commission has not been receiving section 26 monthly visit reports every month although records in the home showed that all but one visit had occurred this year. More recent visits by an new Area manager such as November 2006 contained more detail in their reports. A common failure in these reports is that the timing of the visit often coincides with few Residents in the home or that the reports contain no reference to interaction or observations of Residents. It was positively noted that the last report made reference to improving practice in this respect. No requirements or recommendations were made as outcomes for Residents are at least good or excellent. The new organisation Evesleigh who oversee the home have been advised by the manager to ensure that any planned changes to systems take into account the specialised and very different nature of this service compared with other homes in the local Evesleigh group. The manager indicated plans for further improvement of the service over the coming year such as relocating an laundry room and ensuring that a particular Resident is supported to remain in the home, and that 3 Residents receive speech and language support. None of these aims were found to be written in to an Annual Development Plan. The manager advised that she is to receive support from the area manager to develop a plan as well as carry out a new survey of relatives and other stakeholder’s views to inform this plan. An inspection of incident and accident records showed that there were no significant events, which have needed to be reported to the Commission. The Commission have been written to since the last Inspection due to the changing behaviour of one Resident although this has not had an affect on the welfare of others based on the incident records seen which includes recording near misses. The management of this situation was found to be sound. There is a detailed health and safety risk assessment of the building in place. Records showed that all equipment in the home is serviced at regular intervals and The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 25 there was a wide range of certificates confirming this. Staff training in health and safety areas such as first aid is kept up to date. The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 4 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 4 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 4 34 X 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 3 X 3 X 3 3 X The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations That the Registered Person ensures that the existing aims or goals for each Resident are recorded within the care plan in order to measure the quality of care when the plan is reviewed. That the Registered Manager completes the Registered Managers Award as soon as possible That the Registered Person ensures that Annual Development Plans for the continuous improvement of the service are recorded and published. 2. 3. YA37 YA39 The Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Mountain Ash DS0000021252.V322269.R01.S.doc Version 5.2 Page 29 - 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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