Care Home: Mount Hermon

What the care home does well Mount Hermon provides a homely, comfortable and attractive place for people to live in. The atmosphere in the home was relaxed and members of staff were cheerful and very helpful. The Providers have taken account of the needs of people with dementia and this is reflected in the design of the environment. Care plans and all documentation were well presented, organised and up to date. The health needs of people living in the home are monitored and appropriate advice and treatment is sought. Relatives said, "My relative is very happy at this care home and she has flourished in the time that she has been here." "I am very satisfied with the care she receives. She is given such love and attention and is always perfectly clean and well fed." "I am fully satisfied with the care provided." "I feel the security in the home gives me peace of mind."The food is of a good standard and the dining room is attractively laid out so that people have a pleasant place to eat. The Providers have consulted a nutritionist recently to ensure people receive a good and balanced diet that promotes well being. There is a good training programme and members of staff have received training in understanding dementia. Staff said that they are well supported and that the manager and the providers are available and encouraging. What has improved since the last inspection? A deputy manager has been employed to assist with the management duties in the home. A bathroom has been completely refurbished and an assisted bath fitted. Many areas of the home have been redecorated. The hallway has been attractively presented with artwork. The garden has been improved with raised flowerbeds and handrails put in around the garden to improve safety. What the care home could do better: There have been no requirements made at this inspection and the overall standard of care provided is good. However there are some recommendations made that if put in place would improve the service further. Further training and guidance to be provided to staff in respect of working with challenging behaviour. Each person living in the home has a clear record of health checks in relation to dentist, optician etc to improve the monitoring of these checks. That new members of staff receive training in safe handling of medication as a matter of priority. This is to ensure that there is always a member of staff on duty who can administer medication. That a member of staff is made available to be around the lounge areas in the mornings to sit and talk with people or provide some form of stimulation. That the menu be displayed and people living in the home told what the main meal of the day is and what alternatives are available. CARE HOMES FOR OLDER PEOPLE Mount Hermon 85-87 Brighton Road Lancing West Sussex BN15 8RB Lead Inspector Jan Aston Unannounced Inspection 09:30 18 March 2008 th 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 Mount Hermon DS0000014635.V360740.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. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Hermon Address 85-87 Brighton Road Lancing West Sussex BN15 8RB 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) 01903 752002 Mrs Wendy Rosemary Gray Mr Mark Andrew Gray Mrs Christine Turner Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate up to two service users in the category Mental Disorder aged fifty-five years and over. 21st June 2006 Date of last inspection Brief Description of the Service: Mount Hermon is a privately owned care home providing personal care for a total of thirty people in the category Dementia over the age of sixty-five years. The registration makes provision for two persons who may be in the category of Mental Disorder, aged fifty-five years and over. The registered persons are Mrs. W. Gray and Mr. M. Gray and the registered manager is Mrs Christine Turner. The property is a large detached house situated on a main bus route on the seafront and five minutes walk from the town centre of Lancing. Parking is available to the front of the property. Resident’s accommodation is provided on the ground and first floors. A passenger lift allows access to the first floor. Two bedrooms on the first floor are not accessible via the lift and are only suitable for residents who are mobile and able to manage stairs. Accommodation is provided in twenty-eight single and one double room. Nineteen rooms now have en-suite facilities. There is a garden to the rear of the property including a large patio area with seating and tables for residents’ use. The home’s fees range from £480 to £800 per week. Mount Hermon DS0000014635.V360740.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 Star. This means that people who use this service experience good quality outcomes. Prior to the inspection surveys were sent to the manager to distribute to people living in the home, relatives, members of staff and Health Professionals. An Annual Quality Assurance Assessment form (AQAA) was completed and sent to the Commission prior to the inspection. Five surveys were received from relatives in time to inform this inspection. A visit to the home was made on Tuesday 18th March and eight hours were spent in the home. The Inspector looked around the home, examined a sample of records in relation to care plans, training, staff, complaints, accidents and Health and safety checks. Four members of staff were spoken with privately during the visit. Due to the nature of the disability of people living in the home the Inspector spoke generally with people living in the home and spent periods of time observing during coffee and lunch time. One person living in the home was spoken with privately in their room. The Registered Manager was not in the home during the visit but the Deputy Manager facilitated the inspection well. The Registered Provider called into the home to receive feedback about the findings of the inspection and was very receptive to recommendations for further improvement in the service What the service does well: Mount Hermon provides a homely, comfortable and attractive place for people to live in. The atmosphere in the home was relaxed and members of staff were cheerful and very helpful. The Providers have taken account of the needs of people with dementia and this is reflected in the design of the environment. Care plans and all documentation were well presented, organised and up to date. The health needs of people living in the home are monitored and appropriate advice and treatment is sought. Relatives said, “My relative is very happy at this care home and she has flourished in the time that she has been here.” “I am very satisfied with the care she receives. She is given such love and attention and is always perfectly clean and well fed.” “I am fully satisfied with the care provided.” “I feel the security in the home gives me peace of mind.” Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 6 The food is of a good standard and the dining room is attractively laid out so that people have a pleasant place to eat. The Providers have consulted a nutritionist recently to ensure people receive a good and balanced diet that promotes well being. There is a good training programme and members of staff have received training in understanding dementia. Staff said that they are well supported and that the manager and the providers are available and encouraging. What has improved since the last inspection? What they could do better: There have been no requirements made at this inspection and the overall standard of care provided is good. However there are some recommendations made that if put in place would improve the service further. Further training and guidance to be provided to staff in respect of working with challenging behaviour. Each person living in the home has a clear record of health checks in relation to dentist, optician etc to improve the monitoring of these checks. That new members of staff receive training in safe handling of medication as a matter of priority. This is to ensure that there is always a member of staff on duty who can administer medication. That a member of staff is made available to be around the lounge areas in the mornings to sit and talk with people or provide some form of stimulation. That the menu be displayed and people living in the home told what the main meal of the day is and what alternatives are available. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 7 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. Mount Hermon DS0000014635.V360740.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 Mount Hermon DS0000014635.V360740.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 3 and 6 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information that they need to make an informed choice about where to live. People have their needs assessed before a decision is made about them moving to the home. People have the opportunity to visit the home before they make a decision to move in. Intermediate care is not provided in the home. EVIDENCE: The home has a Statement of Purpose that is specific to the home and includes all the information about the service that a prospective resident or their relatives would need before they moved into the home. Photographs have been used within the document to improve the presentation for people with a dementia. Five surveys were received from relatives that indicated that they had received enough information about the home before their relative moved in. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 10 From the sample of care records examined it was demonstrated that the registered manager had undertaken an assessment of a person’s needs prior to their admission to the home. One assessment had been undertaken at a person’s home and another whilst the person was in hospital. Information about the person’s needs had been obtained from relatives and from Health professionals. From the assessments that are undertaken prior to admission a care plan is compiled that states the person’s needs and wishes and how the service will meet those needs. Prospective residents also have an opportunity to visit the home with their relatives or spend time in the home before agreeing to stay permanently. It was noted from one of the pre-admission assessments that a person had been invited for lunch before moving into the home. This admission process ensures that there is a planned admission wherever possible and members of staff have sufficient information about how to support a person when they are admitted to the home. The Deputy Manager confirmed that intermediate care is not provided in this setting. Mount Hermon DS0000014635.V360740.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A person’s health, personal and social care needs are set out in an individual plan of care that demonstrates the health and personal care that people receive is based on their individual needs. Medication is administered according to recommended guidelines. The principles of respect, dignity and privacy are put into practice. EVIDENCE: A sample of five care records was examined. Within each file there is a photograph of the person, a pre-admission assessment, a care plan at a glance information sheet, a belongings register, fire procedures, electrical equipment check, risk assessments in respect of going out, falling, skin condition, challenging behaviour, locks on doors, a person’s weight is recorded and there is a full care plan that documents the person’s needs. A person’s life history is also written down to help with understanding a person and communicating with them or when assisting them to make decisions or choices. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 12 The Registered Manager and Deputy have also compiled a document to record information about a person’s capacity to make decisions. It also records some of their wishes and choices. The care plans covered all aspects of a person’s needs and had been reviewed on a monthly basis. Members of staff have some guidance about how to support a person where they may become verbally or physically aggressive due to the nature of their disability. Members of staff spoken with confirmed that they have been given information about how to approach a person and to keep the situation calm. Where it is in the person’s best interests to receive personal care support and members of staff may have to hold the person’s hands in order to provide this then training and further guidance must be provided. It is also recommended that a separate record is made when this situation occurs to effectively monitor any pattern or triggers for this behaviour. It was evident from speaking with members of staff and from examining the daily records for each person that health professionals are called in where necessary. However it was not easy to see from the records when a person last had a check up in relation to their sight, hearing, teeth/mouth, chiropody or an annual health check. It is recommended that a separate sheet in each person’s files be kept that records all health checks. The care file for each person also contains an information sheet that can be given to an ambulance crew or health professionals if the person is admitted to hospital. A relative also said, “When my relative has had to go to hospital the care home never fails to send her there with a care to keep her company and stay with her so she has someone familiar with her.” The training provided for new members of staff ensures that they receive a good induction that covers all aspects of supporting a person with personal care. Members of staff spoken with confirmed that they had received an induction training programme when first starting work in the home and this had provided the necessary information and guidance and they felt well supported. The storage and administration of medicines in the home was examined and was organised and in good order. The Inspector observed the administration of medication that was undertaken according to guidelines. There are no people living in the home who are able to take their own medication. The documents used for recording whether a person has taken medication were seen and had been completed appropriately. Members of staff confirmed that they are not allowed to administer medication unless they have been trained. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 13 From training records it could be seen that members of staff had received training in safe handling of medicines. Out of the sample of five staff records that were examined three people were new so had not received this training. It is recommended that the Registered Manager ensure that new members of staff receive training in safe handling of medication as a matter of priority. This is to ensure that there is always a member of staff on duty who can administer medication. People living in the home said that members of staff who support them are kind, gentle and respect their privacy. The relatives who returned surveys said, “Staff are very approachable and helpful.” “The attitude of the staff to the residents is excellent, caring, friendly, helpful and cheerful. They show respect and kindness to everyone.” Mount Hermon DS0000014635.V360740.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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their life style. A varied programme of activities ensures that people have opportunities to satisfy their social, cultural, religious and recreational interests and needs. People have nutritious and attractive meals and snacks. EVIDENCE: An activities organiser is employed to work in the home from Monday to Friday. A person also comes into the home to hold reminiscence sessions. Trips are organised every so often to the theatre, they hold garden parties and fetes and have musical entertainment coming into the home. There is a reminiscence lounge on the first floor that has items of interest that might bring back memories or create a conversation or discussion. There are two lounges on the ground floor with televisions in each. It was noted that only one lounge had the television on so people living in the home had a quieter lounge to sit in. The garden at the rear of the home provides an attractive safe environment for people to sit or wander around. Raised flowerbeds have been put in and form part of a sensory garden. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 15 The activities usually take place in the afternoon when the activities organiser comes on duty. During the afternoon of the visit to the home the activities person was playing cards and dominoes with a group of people in the dining room. During the visit it was observed that staff were busy in the mornings and there was not a lot of time for sitting and talking with people or for any other activity with them. This meant that people living in the home received little attention from staff. It is recommended that a member of staff is made available to be around the lounge areas in the mornings to sit and talk with people or provide some form of stimulation. There are no restrictions on visitors or visiting times. A relative said, “ I visit regularly, I always get a lovely, friendly welcome from every member of staff I run into.” “Visits by relatives and friends are welcome at any time without notice.” People living in the home may not always be able to make decisions or choices due to the level of their disability. The care records include a statement and information in relation to the Mental Capacity Act for each person and whether they are able to make decisions or choices. Members of staff are instructed to support an individual to make choices about all aspects of their day as much as possible. Where known a person’s personal choices in respect of clothes they like to where, the food they like to eat and what they like to do is recorded. Where a person cannot make decisions relatives or an advocate will be contacted. It was observed in the morning when tea was being served that members of staff did not ask whether people wanted tea or coffee they just gave them a drink. This does not promote or maintain a person’s capacity to make decisions for themselves so this should be addressed with members of staff. During this observation a member of staff assisted a person with a drink; she talked to the person, listened to them and responded genuinely even though the person’s conversation was quite confused. The Providers have just consulted a nutritionist about the menus and food provided. The nutritionist’s report was seen. Some good practice recommendations have been made and the Providers are reviewing the menus with the cook to ensure that people receive a good wholesome diet. A person’s nutritional needs are assessed on admission to the home and then monitored. Where a person has difficulty in eating a balance diet due to their disability or illness their food and fluid intake is monitored and recorded. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 16 The Inspector observed the lunch time period. This was well organised, calm and unrushed. Where people ate in their rooms they received their meals in good time and members of staff had sufficient time to assist them where necessary. The Inspector ate the main meal of chicken curry and apple crumble and cream for desert. This was cooked and presented well. One resident said she would not have chosen curry “it is not something she likes”. She said that she does not know what food is going to be served until it is put in front of her and then she has to say that she does not like it. It is recommended therefore that the menu be displayed and people living in the home told what the main meal of the day is and what alternatives are available. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives can be confident that their concerns and complaints will be listened to and acted upon. There are measures in place to ensure that people are protected from abuse. EVIDENCE: The complaints policy and procedure is provided in the Statement of Purpose and is given to people living in the home and their relatives. The complaints procedure is displayed in the entrance hall. All of the relatives who returned surveys said that they knew how to make a complaint to the home. A relative said, “There is a notice in the hallway saying how to make a complaint and also the Manager is usually in the office and available if a problem arises.” There is a system for recording complaints to show the detail of the complaint, the timescales of the response and the outcome. The Annual Quality Assurance Assessment form that was completed by the Manager prior to the inspection recorded that no complaints had been received. The Commission has not received any complaints about this service. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 18 The service has a policy and procedure in place in respect of safeguarding adults. Members of staff spoken with were aware of how to recognise signs of abuse and to report any allegations in line with the West Sussex Social and Caring Services Safeguarding Adults Procedures. All newly appointed members of staff receive information about safeguarding procedures as part of their induction and there is an ongoing programme of training in recognising and reporting signs of abuse. There was a safeguarding adult referral in respect of the service in July 2007. The safeguarding adult team from Social Services investigated but found inconclusive evidence but made some recommendations for improving care records. The Registered Manager and Providers have made changes in respect of the recommendations made. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 19 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: Mount Hermon provides a comfortable and homely environment for people to live in. Considerable re-decoration and refurbishment has been undertaken in bedrooms, entrance hall and in the garden. A fitted cupboard area in the hall way has been fitted with an attractive piece of artwork making it look like a tearoom. All areas of the home look attractive, clean, bright and well maintained. A full time maintenance person is employed so that any repair is undertaken quickly. The AQAA records that Health and safety checks and inspections have been undertaken on gas, electricity, portable appliances, the lift, hoists, emergency call system, heating and the fire detection system and equipment. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 20 A fire risk assessment is in place that covers all areas of the home and evacuation plan. Hot water outlets have been fitted with thermostatic valves to regulate the temperature to prevent scalding. Radiators and pipe work throughout the home are covered to minimise the risk of burns. Bedrooms looked clean and comfortable and had been personalised with the person’s belongings. Either nameplates or photographs have been placed on people’s doors so that they can easily be recognised by them. People can leave their doors open but still be safe in the event of a fire as door guards have been fitted that are linked to the fire alarm. Any necessary equipment is provided such as hoists, moving and handling equipment, pressure relieving mattresses and cushions. Coded locks have been fitted onto the front door and doors at the top of the stairs to improve security. Any person remaining in their rooms during the day still have access to all areas of the home through using the lift. All areas of the home were clean and hygienic. There are sufficient numbers of domestic staff to keep the home clean. All members of staff receive training in the prevention of infection and understand the need for good hand washing and the use of protective clothing and gloves. A hand gel has been provided in the entrance hall for visitors to use to prevent the spread of infection. It is recommended that a book be kept in each bathroom to record the hot water temperature when assisting a person with a bath. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 21 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meets the needs of people living in the home. People are safeguarded by the home’s recruitment policy and practices. Members of staff are trained and competent to do their jobs. EVIDENCE: The Annual Quality Assurance Assessment form that was completed by the Provider confirmed the number, ages, gender and ethnicity of staff employed to work in the home. In relating this information to the number, gender and ethnicity of people living in the home the mix of people in the staff team is appropriate to meet their needs. The staffing levels on the day of the inspection were appropriate and members of staff spoken with confirmed that the staffing levels allowed them to provide support at a resident’s own pace and to have time to talk with them. The amount of training that has been undertaken by the staff team ensures that the staff team have the skills and experience to meet the needs of people well. Members of staff spoken with confirmed that they have received a good level of training from induction through to working to National Vocational Qualifications (NVQ). So far seven members of staff have achieved NVQ 2 and four members of staff are currently working towards this. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 22 Topics covered in training are relevant to the work members of staff are expected to perform and covers all areas of mandatory training and other topics such as understanding dementia, safeguarding adults, infection control and other illnesses or disabilities. The sample of recruitment records showed that the home operates a robust recruitment process and all the required checks are carried out prior to new staff starting in post. Members of staff are supervised on a daily basis and have received formal individual supervision from the manager. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 23 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, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a person with the knowledge and experience to do so. The quality monitoring systems ensure that all areas of the home are run in the best interests of people living there. People’s financial interests are safeguarded. The health, safety and welfare of people living in the home and staff are promoted and protected. EVIDENCE: The Registered Manager was not present during the inspection. The Registered Manager Mrs Turner is an experienced manager and has undertaken the Registered Managers Award. Members of staff told the Inspector that they find the Providers and the Manager approachable and had confidence that they would be listened to. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 24 They said that the Manager and Providers were always available on call in the evenings and at weekends. The Provider has employed a Deputy Manager since the last inspection to assist with the management duties in the home. Relatives said, “I am very pleased with how the home is run and the owners and management have made it a happy and pleasant place to be.” “I am always kept informed of any changes in circumstances.” “The care home has always responded immediately to deal with any concerns that I have informed them of.” There are monitoring systems in place to review the quality of the service provided. This includes very regular visits by the Providers as well as the regulatory monthly inspection visits. The Manager holds regular staff meetings where members of staff said they feel they can raise any issue. Care records are reviewed regularly. Surveys from relatives indicated that the management of the home communicate with them well so they feel they can raise any concern with them. A requirement was made at the last inspection for the Provider and Manager to maintain a system for reviewing at appropriate intervals the quality of care provided at the care home. During the visit there was no evidence of a more formal quality assurance exercise having taken place, as the folder could not be found. The Registered Manager confirmed after the inspection that questionnaires have been sent to relatives and health professionals since the last inspection to obtain feedback about the service and she has reviewed the format used for obtaining feedback in preparation for undertaking another quality review. A further requirement has not been made at this inspection but the Manager is reminded of the requirements of Regulation 24. People living in the home are encouraged to manage their own finances and where they lack capacity to do this relatives or legal advisors assist with financial matters. The Provider and Manager do not act as Appointee’s or hold Power of Attorney for anyone living in the home. The Manager assists people with small amounts of money for additional services and personal expensed; all transactions are recorded and moneys accounted for. The documentation relating to the Health and Safety of the premises was in good order and up to date. Members of staff receive ongoing training in the health and safety topics such as first aid, moving and handling, infection control, fire and health and safety to ensure that the welfare and safety of staff and people living in the home is maintained. Training records provided evidence that this training is regularly available. Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X 2 X 3 X X 3 Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 26 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. Refer to Standard Good Practice Recommendations Mount Hermon DS0000014635.V360740.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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