Care Home: Mellifont Abbey

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What the care home does well Surveys from 7 people who live at the service. All responses were positive in tone. One statement about the service was, "I think the home is excellent." Surveys indicated that people receive the care and support they need, live in a home that is fresh and clean and feel able to raise concerns within the home should they need to. Surveys from 10 staff. Responses were positive regarding staff induction training, recruitment checks at employment, clear policies and procedures at the organisation and supervision. All responses said that they had received training and information on working with vulnerable adults and adult protection awareness. One response stated, "I have found Mellifont Abbey, the staff, residents and management the best place of work in the last 25 years." A survey from 1 relative. This was positive and stated that the staff are "always caring and pleasant." Surveys from 4 community health care professionals. All responses had positive tones. Comments were that the service "provides individual care", that "staff encourage residents` choice" and that "people are involved in the planing of their care." The home has let us know about things that are reportable under Regulation 37 reporting. We have received no complaints about the service. Clear information is provided to people who are looking for a care home and their relatives. This is available in different formats, so that it is accessible for people with different needs. The manager or her deputy completes a full assessment before a person is admitted to make sure the home can meet their needs. People who live at Mellifont Abbey have access to a good range of professionals from other agencies to help with their care, for example GPs, District Nurses and other advisors. People are supported to self medicate when they are able and this helps maintain independence and choice. The staff attend to people in a kindly way. The staff were also praised by relatives for their patience and understanding. People felt safe in their hands. There are good links with the local community and visitors are welcomed, so that the home remains part of the community. The environment is well maintained, clean and warm. People can choose to personalise their rooms with their own belongings and can choose where to spend their time. Staff have access to a good range of training to help them care for people skilfully. Residents are asked for their views and, within the limitations of community living, their suggestions are acted upon. Health and safety is managed effectively, for the safety of all. The home has it`s own transport which is available for use at no extra charge. In addition a caravan situated in Weymouth is now available and it is hoped that this will be used to offer holidays and breaks to people living at the home in the spring and summer months. What has improved since the last inspection? No requirements were made as a result of the Annual service review conducted in 2007. At the last key inspection which was conducted in May 2006 five Requirements and five recommendations were made. At this inspection all these had been met. When the home was purchased by the current owners in 2006 it was in a poor state of repair and did not meet current or expected standards. Since this time significant works have been completed to bring the home up to an acceptable standard. This includes the refurbishment of a number of bedrooms, bathrooms and some communal areas. Where the refurbishment has occurred this has been completed to a high standard. Unfortunately the main stair well has recently had a substantial leak from the roof. Mellifont is grade two listed. Due to this the building and stair well has had to be repaired and restored in line with this status. This has put the refurbishment of the rest of the home back due to the financial and time implications this has caused. CARE HOMES FOR OLDER PEOPLE Mellifont Abbey Wookey Wells Somerset BA5 1JX Lead Inspector Justine Button Unannounced Inspection 23rd September 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mellifont Abbey DS0000064979.V371653.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. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mellifont Abbey Address Wookey Wells Somerset BA5 1JX 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) 01749 672043 mail@mellifontabbey.co.uk Mellifont Abbey LLP Mellifont Abbey Mrs Michele Lesley Aldrich Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (22) Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user under 65 years of age in category MD. Date of last inspection: Brief Description of the Service: Mellifont Abbey is a care home offering personal care for up to 23 older people. The home is of considerable historic interest and retains a number of original features that lend it a unique character. The home is situated in the small village of Wookey, 2 miles from the city of Wells. The village has a pub and church, other facilities are available in Wells, which can be reached by bus or the homes own mini-bus. The home is set in 3 acres of pleasant grounds, which can be accessed by service users who are independently mobile. The large lounge overlooks the garden, which also has a summerhouse. Accommodation is available in both single and shared rooms over 2 floors. The first floor can be reached by a shaft lift, this is not large enough for a wheelchair, and people using a wheelchair would need accommodation on the ground floor. The fees at the home range from £369 - £475. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection was unannounced and completed over the course of one day. The inspector spent the whole day in the home. The home last inspection which included a site visit was in May 2006. In 2007 an Annual service review was completed. We do an annual service review when there has been no major inspection of the service (we call this a key inspection) in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review. During the inspection we talked to residents. Staff and visitors were also available for discussion. The manager helped with the inspection by providing information and records. Pre-inspection information was received before the inspection in the form of the Annual Quality Assurance Assessment (AQAA). This is now required to be completed every year and sent to CSCI. It was completed in enough detail and gave a good overview of the home’s activities, including what it has done well, what has hampered improvements and what is planned for the future. A tour of the premises was made, interaction between staff and people who use the service observed, as well as care practices that included the administration of medicines and the serving of food. The inspector sampled some of the residents documentation along with records relating to staff and other records required by regulation. Surveys were sent out. The responses to these surveys is reflected in the main body of the report. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 6 What the service does well: Surveys from 7 people who live at the service. All responses were positive in tone. One statement about the service was, I think the home is excellent. Surveys indicated that people receive the care and support they need, live in a home that is fresh and clean and feel able to raise concerns within the home should they need to. Surveys from 10 staff. Responses were positive regarding staff induction training, recruitment checks at employment, clear policies and procedures at the organisation and supervision. All responses said that they had received training and information on working with vulnerable adults and adult protection awareness. One response stated, “I have found Mellifont Abbey, the staff, residents and management the best place of work in the last 25 years.” A survey from 1 relative. This was positive and stated that the staff are “always caring and pleasant.” Surveys from 4 community health care professionals. All responses had positive tones. Comments were that the service “provides individual care”, that “staff encourage residents’ choice” and that “people are involved in the planing of their care.” The home has let us know about things that are reportable under Regulation 37 reporting. We have received no complaints about the service. Clear information is provided to people who are looking for a care home and their relatives. This is available in different formats, so that it is accessible for people with different needs. The manager or her deputy completes a full assessment before a person is admitted to make sure the home can meet their needs. People who live at Mellifont Abbey have access to a good range of professionals from other agencies to help with their care, for example GPs, District Nurses and other advisors. People are supported to self medicate when they are able and this helps maintain independence and choice. The staff attend to people in a kindly way. The staff were also praised by relatives for their patience and understanding. People felt safe in their hands. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 7 There are good links with the local community and visitors are welcomed, so that the home remains part of the community. The environment is well maintained, clean and warm. People can choose to personalise their rooms with their own belongings and can choose where to spend their time. Staff have access to a good range of training to help them care for people skilfully. Residents are asked for their views and, within the limitations of community living, their suggestions are acted upon. Health and safety is managed effectively, for the safety of all. The home has it’s own transport which is available for use at no extra charge. In addition a caravan situated in Weymouth is now available and it is hoped that this will be used to offer holidays and breaks to people living at the home in the spring and summer months. What has improved since the last inspection? No requirements were made as a result of the Annual service review conducted in 2007. At the last key inspection which was conducted in May 2006 five Requirements and five recommendations were made. At this inspection all these had been met. When the home was purchased by the current owners in 2006 it was in a poor state of repair and did not meet current or expected standards. Since this time significant works have been completed to bring the home up to an acceptable standard. This includes the refurbishment of a number of bedrooms, bathrooms and some communal areas. Where the refurbishment has occurred this has been completed to a high standard. Unfortunately the main stair well has recently had a substantial leak from the roof. Mellifont is grade two listed. Due to this the building and stair well has had to be repaired Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 8 and restored in line with this status. This has put the refurbishment of the rest of the home back due to the financial and time implications this has caused. 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. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 9 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 Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 10 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, 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are considering living in Mellifont Abbey and those close to them are provided with enough information about the home in a variety of ways. All people moving to Mellifont have their individual care needs assessed before admission to the home is agreed. EVIDENCE: The registered provider has produced a statement of purpose and service user guide along with other brochure type leaflets that give prospective service users and relatives information on the home and service. A copy of the Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 11 statement of purpose was available in the reception area of the home. The AQAA stated that a copy of the service user guide is given to all service users as it is part of the terms and conditions. In the surveys of people who live in the home 100 said they received enough information about the home before they decided if it was the right place for them. Admissions to the home are not made until a full needs assessment is made. The registered manager receives the social worker assessment and then carries out her own needs based assessment. A sample of these was seen in the care plans. They were detailed enough for a decision to be made about whether the home can meet the person’s needs. The home can meet the needs of the people who live there in terms of the skills and experience of staff. In the surveys from people who live in the home all said they ‘always’ receive the care and support they need. The Home said in the AQAA that people can spend a trial period in the home if they are unsure if they are making the right decision. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans and associated reviews need to accurately reflect the care needs of individual’s, however the care and the support being provided was appropriate. Health needs are met Dignity and privacy are considered by staff at all times Medication administered and storage was well maintained. EVIDENCE: Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 13 All of the care plans examined are based upon information provided from preadmission assessments. Following admission to the home, further assessments are carried out and the home draws up a care plan identifying the needs of each individual and how staff are to meet these needs. We viewed three care plans during the inspection. These contained clear and detailed information for staff to follow in order to meet resident’s healthcare & social needs and preferences. Individual care plans are reviewed monthly and updated where necessary. Where the resident wishes their relative to be involved in their care planning reviews, the home has plans to involve relatives on a three monthly basis. Residents have access to a range of professionals including the GP, District Nurse, Community Psychiatric Nurse (CPN), and Social Worker. Interaction between staff and residents were observed as friendly and respectful. Through discussion with the individuals we were informed that the care staff fully respected their privacy and dignity. Residents informed the inspector that they are not made to do anything they did not wish to, such as attending activities or having meals in the dining room. Staff were observed knocking on doors before entering. People who use the service are able to meet privately with visitors in their bedroom or in one of the lounges. They further confirmed that all personal care was provided in the privacy of their bedrooms or bathrooms. The care plans and associated documents supported these representations. Screening is provided in those rooms with shared occupancy. Medicines are stored well. There was a fridge for medicines needing refrigeration and the temperature was being monitored and recorded. One staff member was observed completing a drug administration round during the inspection. This was completed within good practise guidelines. One drug error has been reported to us since the last inspection. This was investigated by the management at the home and appropriate action taken. The home has produced a list of the medicines that each resident takes. This includes information on why the resident takes the medication and identifies the possible side effects. When ‘as required’ medication is administered to residents, the home records the date, time, medicine, dose, reason for administration and signature. The home has a homely remedies box. A homely remedy administration sheet has been introduced for each resident to record date, time, reason for administration and signature. The home are awaiting confirmation of the homely remedies list from the GP. Creams and Lactulose had been dated on opening. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities are well advertised. There is a range of social events and for the less able there are opportunities for one to one social contact. Comment cards indicated that not all people found the availability of activities adequate Families were seen to be welcomed and to be part of the home life. The menu is varied. The food on the day of the inspection was of a good standard. EVIDENCE: The care plans viewed during the inspection detailed the preferences of service users. People living at the home or their Relatives & friends provide information relating to their loved one’s social history, previous hobbies/interests, preferences, likes and dislikes if the individual is not able to provide this information. Those staff observed on the day of the inspection Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 15 appeared to have a good knowledge of the people living at the home and what they did and did not like. Those service users able to express a view informed the inspectors that their wishes were respected and that they could choose what time to get up or go to bed. Service users can choose where and how to spend their day. Any restrictions would be identified in risk assessments. As previously mentioned, staff interacted with service users in a kind and respectful manner. The home employs an activities organiser at the home. The activities records were viewed as part of the inspection. These demonstrated that there is a range of activities on offer when the activities organiser is present. There is a person centred and individual approach to the activities on offer. There was clear evidence that people living at the home are consulted on the activities that they would like to be provided. The home has it’s own transport which enables trips outside of the home to be organised at short notice and when the weather permits. The activities organiser was arranging to take one person out to the local town to purchase new clothes. Records showed that visiting historians and music events have been organised at the home. Arts and crafts are also available. The home has use of a caravan in Weymouth which will be used next year to enable people to take short breaks and holidays. The home has strong links with the local community. The village/church fete was held in the grounds of the home with people who live at the home taking an active role in organising stalls and attractions. People living at the home now access the village hairdresser, with staff support if this is required. This enables people to interact with the local community and provides a sense of “normality” The village church is adjacent to the home and people who wish to practise their faith are supported to attend services at the church. Support for people of varying religions can be arranged although this is not applicable at the time of the inspection. The home has a visiting dog which is appreciated by the people at the home. A summer house in the garden has been provided for those people who wish to smoke. This however is situated away from the main building so does not impact on those people who do smoke. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 16 The gardens were in excellent condition and are accessible to people living at the home. People living at the home were seen to be enjoying the garden and were wandering freely enjoying the outside space. The home welcomes visitors at any reasonable time in accordance with the wishes/preferences of the service user. Visitors spoken to during the inspection were extremely complimentary about the care and support afforded to people living at the home. All meals are prepared and cooked on the premises. The home has an eight week menu. The menu appeared wholesome and varied. The main meal is served at lunchtime with a lighter cooked meal at tea time. This was evident at the time of the inspection. The inspectors were informed that milky drinks and sandwiches were offered in the evening. Special diets are catered for. These were seen to be attractively presented. Sweets were available for those requiring a diabetic diet. A cooked option is also available at breakfast. Staff were observed assisting service users in a manner which was relaxed, unhurried and respectful. Service users able to express a view were positive regarding the meals available and stated that there was always plenty to eat. Drinks were served throughout the day. A range of cakes or biscuits was available. A choice of meal is available at all times. Some people living at the home had forgotten what they had ordered. Some people may have difficulty in expressing a preference. Staff were observed to be showing the plates of food to those with communication issues to ensure that a choice could be made more readily. The tables were set with tablecloths, napkins and appropriate condiments. A range of cold drinks was available through the meal. Menus are on display in the dining room. A choice of sweets and puddings were available following the main meal. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 17 Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with in line with the homes policy and procedures. People living at the home are aware and comfortable in expressing any concerns. People living at the home are protected by the home’s policies and procedures. Staff have received recent training in the prevention and recognition of abuse. EVIDENCE: Feedback forms to people living at the home asked do you know who to speak to if you are not happy? Comments from relatives included “A wonderful home no complaints”. The Home has a complaints procedure that is clearly written and contains the contact details for CSCI. All the complaints are dealt with in line with the homes policy and procedure. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 19 A range complimentary letters were also held on the file. The policies and procedures regarding protection of residents are of a good standard, which include complaints,recognising signs of abuse and whistleblowing. Abuse training is included in the new staff induction programme. The training matrix was viewed as part of the inspection process and this showed that staff had not recived abuse training, althouhg this is covered by staff who have completed an NVQ and during induction. Since the last inspection the manager has been proactive in welcoming complaints and suggestions about the service, using these positively and learning from them. This includes a suggeation box which is situated in the main enterance. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, 26. The quality in this outcome area is adequate. The home is committed to improving its facilities. Residents have their own possessions in their room. The home was clean and tidy. EVIDENCE: During the inspection we discussed the ongoing maintenance to building. The manager explained that there are plans to extend the home to provide an extra five beds. He manager also explained that main stair well in the home has had a leak from the roof causing damage to the plaster and decor. Melifont is grade two listed. Due to this the roof had to be repaired and restored in line with this status. This has put the refurbishment of the rest of the home back due to the Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 21 financial implications that this has caused. The manager explained however that this has not lessened the commitment to the ongoing improvement to the home. The refurbishment of 8 bedrooms has been completed. Those that have been completed have been done to a high standard and are much improved on the previous decor. Emergency lighting has all been renewed. A new nurse call bell system has been installed Some bathrooms have been refurbished again these have been completed to a good standard and are much improved. The Kitchen was viewed during the inspection and this requires updating. This is in the planed to take place when the extension is being completed. The Inspector spoke with the resident who had moved into this room. They were very happy with the décor and they stated that the new furniture was very comfortable. Resident’s rooms are personalised with their own possessions. Hot pipework has been guarded since the current owners purchased the building. Water temperatures are being monitored and records were available. These were maintained at close to 43 degrees Celsius. The home was clean throughout. There was a malodour in one bedroom. The laundry was clean and tidy. Liquid soap and hand towels are provided. Staff were observed wearing aprons and gloves. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. The quality in this outcome area is good. There were sufficient staff on duty to meet resident’s needs. Staff recruitment procedures are robust and protect residents. The home has a comprehensive staff training programme although not all staff had completed this. EVIDENCE: Duty rotas covering the previous two weeks were viewed. Three care assistants were on duty in the morning and two care assistants were on duty in the afternoon/evening. The home has twe people on duty at night and the manager is available if required. The Inspector observed that there were sufficient staff on duty to meet the resident’s needs and staff were able to give time to residents. The residents spoken with confirmed that staff are always available. Comments included “I’m well looked after” and “nothing is too much trouble”. We viewed three staff recruitment files. These included all of the required documentation. The home has a detailed pre-employment medical Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 23 questionnaire; an equal opportunities monitoring form; an interview record form; and a checklist to ensure that all the required information is collected. This is good practice. The home gives new staff a copy of the GSCC Code of Practice. The home has a comprehensive training programme. A training matrix provides an overview. Each member of staff has an individual training file. Training areas include first aid, moving and handling, risk assessments, food hygiene, health & safety, palliative care, dementia, dental health, abuse awareness, medication and infection control. The training matrix confirmed seven staff have an NVQ 2 in Care and two staff have a NVQ 3. All (except two) have now completed fire training. The home must arrange for the remaining staff to complete this training. On viewing the training matrix it was evident that two staff have received no training. This was discussed with the manager who stated that these staff work on a very part time basis. All staff even those who work on a very part time basis need to complete training in line with their job role. The manager agreed to review this. The home had developed an improved induction programme. When new staff start work they spend their first two working days on induction. The Inspector spoke staff. They confirmed that they had an induction. They demonstrated a good awareness of how to respect resident’s privacy, what to do if they suspected abuse, and what to do in the event of a fire. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38. The quality in this outcome area is good. The home is well run and managed. There is an emphasis on involving residents and staff in the running of the home. The home’s quality assurance systems ensure that the home is run in the best interests of the residents. Resident’s money is safeguarded. The home need to ensure that people living at the home have access to personalised bank accounts Staff receive regular supervision. The home is committed to improving health and safety. Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 25 EVIDENCE: Mrs Aldrich is the Registered Manager. She has experience in managing care homes. Mrs Aldrich holds NVQ 4 in Care and has now completed the Registered Manager’s Award. She plans to undertake an Assessor’s Award. All staff and residents spoken with confirmed that the manager is very approachable. Staff comments were very positive. Staff confirmed that they receive regular supervision and feel well supported. Residents spoken with commented that they enjoyed the resident’s meetings. Minutes of the last meeting were viewed. These contained evidence that the residents are actively involved in the meetings. Some of the items discussed had already been actioned. Somerset County Council has accredited the home with a quality rating. The home has also carried out a ‘quality and service’ survey. This asked for resident’s views on the refurbishment work, food, activities, staff, care, choice, and any improvements. The home has already introduced a vegetable garden; purchased new lounge furniture, garden furniture and plants as a result of these meetings. The home has also introduced a suggestion box and this has been placed in the hall. The home stores money for some residents. This is kept securely in the home’s safe. Records were viewed and there was an audit trail for monies spent. Two signatures are obtained for all deposits and withdrawals and cash is reconciled each time. Two of the residents’ monies were checked. One balance was correct. Execss monies are kept in a “pooled” bank account. The manager stated that this is an interest giving account. The interest is factored to the amount that the individual has in the account. This is not best practise and people living at the home should have their own accounts. The Inspector viewed some of the home’s health and safety records. These were in line with good practise The home’s fire alarm system and emergency lights are serviced regularly. The home has reviewed the position of fire extinguishers on the wall and these have now been positioned at a suitable height. The home tests the fire system weekly. Emergency lights are tested monthly. Mellifont Abbey DS0000064979.V371653.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 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Mellifont Abbey DS0000064979.V371653.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 OP19 Good Practice Recommendations Maintenance and on-going improvements are required to ensure that décor, fittings, furnishings etc. are well maintained, comfortable and suitable for us. This progress will be monitored at each inspection All staff including those who work on a very part time basis must receive training in line with their job roles. The management should review the policy of some personal monies being held in a pooled account. 2. 3. OP30 OP35 Mellifont Abbey DS0000064979.V371653.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Mellifont Abbey DS0000064979.V371653.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. 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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