Care Home: Mountview Community Support Centre

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What the care home does well Mountview Community Support Centre provides pleasant and rewarding short stays for users of the service. All contact with them and their family members was positive about the care in the home which they felt was of a good standard. Comments included "the home does well in everything in its capacity" and "I am well looked after". The premises are of a good standard and there is a full management team in place to support the work. The home has full policies and procedures to underpin its work and has provided a very high level of vocational training for staff. The home ensures a Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 good standard of meals and has an individualised approach to care based on individual care planning. The home is a safe environment for people staying there with comprehensive procedures in place for their safety. What has improved since the last inspection? Since the last inspection a single registered manager has been appointed which represents a distinct improvement on the previous, split post. As a result, certain longstanding issues in the home have started to be addressed although further progress in some areas is still required. However, the activities available to people staying in the home have been significantly increased to allow more active stays. In addition, some training needs have been addressed and a programme of supervision has been instigated although it is not fully established. Equally, the registered manager has been seeking to improve and expand the key worker role so that greater continuity of care is provided. Again, this is a recent development and the full impact can not yet be ascertained. The home actively seeks to obtain feedback from users of the service and, by analysing the results, to make improvements to its service. What the care home could do better: Although the registered manager can show that he is seeking to improve the training available to staff, there are still deficits in the provision and recording of training which detracts from the process. Equally, although formal supervision has been introduced and more is planned, there is a considerable way to go before this meets the needs of staff in the home. The most immediate issues arising from the inspection relate to the admissions of inappropriate people to the home. Concerns were expressed by staff about their ability to care for people with dementia and there are a number of recorded incidents of people being admitted who have required transfer following admission. The registered manager has taken steps to reduce this but further work must be undertaken in terms of the registration of the home and the assessments of people who use the service.Mountview Community Support CentreDS0000036720.V375408.R01.S.doc Version 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Mountview Community Support Centre Melton Drive Congleton Cheshire CW12 4YF Lead Inspector Mr John Mullen Key Unannounced Inspection 09:00 8 September 2009 th DS0000036720.V375408.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountview Community Support Centre Address Melton Drive Congleton Cheshire CW12 4YF 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) 01260 375 588 01260 297386 helen.riley@cheshire.gov.uk http/www.cheshire.gov.uk Cheshire County Council Gareth Davies Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (6) of places Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This care home is registered for a maximum of 36 service users to include: * Up to 36 service users in the category OP (Old age not falling within any other category) * Within the total of 36, up to 5 service users may be in the category PD (Physical disability aged between 55 and 65 years) * Within the total of 36, up to 1 service user may be in the category PD (Physical disability aged between 50 and 65 years) 7th August 2007 Date of last inspection Brief Description of the Service: Mountview is a community support centre providing personal care and accommodation on a short stay/respite basis. It provides accommodation for thirty six older service users, including up to five people with disability aged between, 55 and 64 years and one person with a physical disability aged 52 to 53 years. It is owned and managed by East Cheshire Council, which operates a number of similar facilities. The registered manager is Gareth Davies. The fees at Mountview are based on a financial assessment of peoples’ means. Mountview opened in August 1988 and consists of a two-storey building. Part of the ground floor has been adapted to provide office accommodation for the home and for the community based services that operate from the building. In addition, a day centre is based on the ground floor which is also used by people staying in the care home. All the bedrooms are single rooms although two can be adapted for couples. Access between the ground and the first floors is via stairs and a passenger lift. The garden is fully accessible. Mountview Community Support Centre DS0000036720.V375408.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. This was a key unannounced inspection of Mountview Community Support Centre Care Home which included a visit to the service. All key standards were assessed in addition to a selection of other standards. This inspection encompassed information received since the last inspection. In addition it included information provided by the agency through its Annual Quality Assurance Assessment document (AQAA). The AQAA gives an overall picture of the performance of the agency as well as factual information about the service. Interviews took place with the registered manager, two senior community support workers and two community support workers. In addition, the cook and other support staff were spoken to. Four users of the service were case tracked; that is their support was examined in detail. Surveys were received from users of the service, relatives and staff. The premises were inspected and a large amount of documentation examined. What the service does well: Mountview Community Support Centre provides pleasant and rewarding short stays for users of the service. All contact with them and their family members was positive about the care in the home which they felt was of a good standard. Comments included “the home does well in everything in its capacity” and “I am well looked after”. The premises are of a good standard and there is a full management team in place to support the work. The home has full policies and procedures to underpin its work and has provided a very high level of vocational training for staff. The home ensures a Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 6 good standard of meals and has an individualised approach to care based on individual care planning. The home is a safe environment for people staying there with comprehensive procedures in place for their safety. What has improved since the last inspection? What they could do better: Although the registered manager can show that he is seeking to improve the training available to staff, there are still deficits in the provision and recording of training which detracts from the process. Equally, although formal supervision has been introduced and more is planned, there is a considerable way to go before this meets the needs of staff in the home. The most immediate issues arising from the inspection relate to the admissions of inappropriate people to the home. Concerns were expressed by staff about their ability to care for people with dementia and there are a number of recorded incidents of people being admitted who have required transfer following admission. The registered manager has taken steps to reduce this but further work must be undertaken in terms of the registration of the home and the assessments of people who use the service. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Mountview Community Support Centre DS0000036720.V375408.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 Mountview Community Support Centre DS0000036720.V375408.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is accommodating people on occasions outside its remit, which is detrimental to their wellbeing. EVIDENCE: The registration certificate was prominently displayed and confirmed that the home is registered to provide accommodation for older people with some younger adults in the physical disability category. However, discussions with both the registered manager and other members of staff confirmed that there is an increasing demand for accommodation for people with dementia which care workers interviewed felt they were not trained to provide. The registered Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 10 manager felt this was less of a problem but did admit that there are a proportion of people staying at the home who were in this category which means that the registration of the home needs to be reconsidered. The visit to the home included a review of both the Service User Guide and the Statement of Purpose and showed that both were of a good standard and provided full information to users of the home. A review of evidence raised concerns about the assessment process because of the need for a number to be transferred subsequently. This was confirmed by interviews with staff who felt that, on occasions, inappropriate admissions were being made due to inadequate assessments. The registered manager also felt this to be the case meaning that remedial action has had to be taken as a result. An examination of files of people staying in the home found that assessment material was available to direct staff. However, staff felt in some cases the information was not complete and one could give evidence of a recent incident when a medical condition was omitted from the assessment which caused concern. The registered manager gave evidence of his attempts to reduce this through more thorough vetting processes. However, the conclusion was that the assessments need to be improved and the role of the home clarified with the referring agencies, so that inappropriate admissions are reduced and, as a result, the unnecessary movement of people staying in the home is limited. Mountview Community Support Centre DS0000036720.V375408.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have been recent improvements in practices which have resulted in a higher standard of personal care. EVIDENCE: The AQAA stated that there were full individual care plans in place to direct staff and that the home is committed to a more person centred approach to care to ensure individual needs are met. An examination of the files of people staying in the home found care plans place in each which could be used to direct practice. Staff interviewed had a mixed view of the usefulness of the plans but, overall, felt they met their purpose. An examination of the files of people staying in the home found that each contained a section specifically on health matters to ensure that these were Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 12 known and met. As noted earlier, a review of evidence has found a high proportion of people with medical problems and this was confirmed by interviews with staff who felt that the disabilities of people staying in the home were increasing over time. The AQAA confirmed that the home has full procedures to promote the health needs of people staying there and this was confirmed by the visit to the home which showed that, for example, both doctors visiting to meet specific requests and the presence of a nurse advisor to act as a consultant to staff. Since the last key unannounced inspection there was one major complaint to us which involved the incorrect storage and administration of medicines. An independent investigation of this complaint upheld this aspect and required the home to make improvements in practice. The visit to the home confirmed that this has been done. The registered manager has introduced a new risk medical assessment for each person staying there which represents progress in this area. In addition, the practice has been improved of checking medicines to ensure that correct procedures are followed. An examination of sheets recording medication found them correct to show good practice. Training documents seen and interviews with care workers showed both that they had been trained in this area and felt confident in their practice. All surveys from people who use the home and their relatives were complimentary about the personal care they were receiving from the home. Comments included “it is very well run by the staff” and “all the carers know my mum very well”. These comments were confirmed by interviews with people staying in the home during the visit there which included comments “I am well looked after” and “no complaints”. An interview with the registered manager showed that he is attempting to expand the key worker role with staff to increase the individualised care for people staying there. Staff interviewed had a mixed view of the effectiveness of this which is limited by both the respite nature of the care and the fact that all care workers are part time workers. However, the registered manager felt that this would improve over time given a positive approach by staff. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has significantly improved the activities available so that people staying there can be occupied positively. EVIDENCE: Both the last key inspection and the Annual Service Review found that the quality and quantity of activities available were not of the required standard to occupy people staying in the home. The AQAA acknowledged this had been a problem but stated that it has been thoroughly addressed to provide varied and stimulating activities for them. The registered manager confirmed that this was the case and that all the activities listed in the AQAA have now been introduced for their benefit. Although some staff felt there had been a low uptake of these the registered manager stated that this had improved through the re-siting of the activities in the day centre. Surveys from families and people who use the service and contact with them of the day of the visit to the home did not raise any overall concerns in this area. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 14 The home provides short term or respite support and, therefore, the question of family contact does not arise as a matter of course. Contact with family members and users of the service through surveys and interviews did not reveal any problem in this area. The home’s policies allow for open visiting to ensure that family links are maintained where necessary. The AQAA confirmed that the home is committed to maximising the independence of people staying there though policies and procedures. However, it also confirmed that their capacities had generally declined so that more direct help is required. Interviews with staff confirmed that this was the case and that, in particular, the admission of people with dementia has increased and affected the home’s role as a result. A tour of the premises and interviews with users of the service found them being encouraged to exercise choice where this is possible and to be happy with their care generally. An interview with the cook and examination of menus confirmed that the home provides a varied and balanced diet based on individual preferences. In addition, the home provides an alternative with each meal plus further choices if neither is acceptable so that individual preferences are met. The visit to the home included observation of the lunchtime meal and confirmed that it was provided in a pleasant environment with a relaxed and social setting. All people spoken to were very happy with the meal on offer and included the comments “the food is very good” and “it is a lovely dinner”. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has thorough policies and procedures for the safeguarding of people staying there. EVIDENCE: A review of evidence found that there has been one major complaint referred to us since the last key inspection. This was investigated under the Council’s formal complaints’ procedure and during this inspection the registered manager provided a copy of the investigation. This showed that the matter had been thoroughly investigated and that where the home had been found to be at fault the registered manager had instigated action to correct procedures. Otherwise, the home maintains a complaints’ book although it is difficult to follow as the complaints are amalgamated with compliments and comments so that a clear picture does not emerge. It would be preferable if this was rearranged so that complaints are listed separately to show any pattern emerging. The complaints’ procedure is thorough and is present in both the Statement of Purpose and Service User Guide so that this information is readily available. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 16 The AQAA stated that there had been two safeguarding investigations since the last key inspection and a review of evidence showed that they had been referred to us. The AQAA also stated that there had been training in safeguarding for all staff so that they were familiar with these procedures. This was not entirely confirmed by the visit to the home when one member of staff said she had not had this training. Other staff stated they had had such training but it was not recorded in the training records seen to verify this. Staff interviewed did feel confident in the procedures and aware of their responsibilities in this field. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises are fit for purpose to produce a homely and pleasant environment for people staying there. EVIDENCE: A tour of the premises found them of a good standard and suitable for their purpose. The building incorporates a day centre as well as a residential care home although people staying there also use the day centre. The bedrooms were of a good standard being well equipped, well decorated and furnished. Living areas were pleasant and homely so that people staying there could relax in pleasant surroundings. The dining areas were spacious and comfortable so that they can eat in a pleasant environment. The home is well equipped with Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 18 aids to assist people with disabilities and has four sluices so that laundry can be managed appropriately. The kitchen and laundry are appropriate for the number of people accommodated. Surveys from people who use the service and their family members plus contact on the day of the visit found them happy with the premises. The AQAA stated that the home has full policies and procedures to ensure that hygiene standards are maintained. A tour of the premises found them clean and hygienic producing a pleasant environment for the accommodation of people staying there. The home has full equipment to ensure that standards can be maintained. It employs general assistants who are responsible for the domestic and laundry duties within the home and contact with them confirmed that appropriate procedures are being followed. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s procedures result in a good quality of staff being employed. EVIDENCE: Staff surveys received were positive about the work of the home and this generally was also the case with staff interviewed during the visit to the service. Some staff felt there was a need for higher staffing levels given the increased demands resulting from declining capacity amongst people who use the service. All care staff are employed on a part time basis which does create a problem of continuity of care. The registered manager is attempting to expand the role of the key worker as a method of counteracting this. There was a mixed response from staff to this proposal although, as the registered manager stated, this has only just been introduced and will need time to develop. A tour of the premises found that there were sufficient staff to fulfil the duties of the home and that observed interaction was pleasant and friendly. Surveys from people who use the service and their families and comments from them were all positive about the care. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 20 The last key inspection commented on the high level of trained staff in the home and this was confirmed by the AQAA which stated that 95 of care workers have a vocational qualification. In addition, the care coordinators have a higher qualification as do senior staff in the home so that practice is underpinned by training. Interviews with care workers also found that some have additional qualifications to underpin practice. This is home is Council run which commits them to full recruitment and selection procedures for the safety of people who use the service. An examination of staff files found that full and appropriate recruitment material was in place including police checks and personal references. Interviews with staff found no concerns with the recruitment and selection process and with a generally positive view of the work although this was not universal. With the exception of one complaint made to us in the past there has been no concern about the quality of staff being employed in the home. The AQAA stated that there was a full training plan in place to ensure that staff remain up to date in all relevant subjects. An examination of training documents found there was a discrepancy between the printed record and interviews with staff so that a clear picture did not emerge. The registered manager stated that he had asked for a review of training so that needs could be easily identified and he was surprised to find that this had not been completed. Training records did show an adequate level of training and staff felt there had been an improvement to training in the recent past so that their needs were better met. Documentary evidence produced by the registered manager showed that he has been pursuing training for staff with a degree of success to improve matters. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being well managed in the interests of users of the service. EVIDENCE: A review of evidence showed that there has been a change to the registered manager since the last key inspection. He has been in post since June this year and replaced two part time registered managers. All staff spoken to felt this change had been beneficial in producing a single reference point for management. In addition, staff were complimentary about the positive impact the new manager has made in addressing some long standing problems. An Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 22 interview with the registered manager found him very committed to progressing the work of the home and meeting identified problems. The management structure is at present under review as part of an overall redesign of the service which has not yet been completed and is causing the registered manager a degree of concern. The home has developed a quality assurance system using service users and their families as a focus for improvement. The home has a quality standard questionnaire and examples of these showed it is a useful document for gauging users’ views on their stays. The results are analysed centrally and an example of this was also seen which showed it could be used as means of improving practice. An interview with the registered manager also showed he has made some innovations in terms of communication with a newsletter having been circulated to staff and other interested parties. In addition, there had been a team day earlier this year to promote common objectives. The team plan for the years 2008-2009 was also seen which identifies objectives for the home as a means of improving practice. The registered manager in interview was clearly committed to using these and other methods as part of a commitment to increase standards. A review of evidence found no concern with the management of monies in the home for the safety of people staying there. The AQAA stated the home has full procedures for the protection of its users in financial matters. The registered manager stated that the home essentially minimises its involvement with its users’ finances so that liability is limited. It does provide secure storage of valuables with appropriate documentation to prove safe handling. The AQAA stated that the home is fully committed to the formal support of staff so they can be helped to develop in their work. However, the visit to the service found that there were significant deficits in the amount of formal supervision that has taken place. Interviews with staff found that, historically, they had received very little formal supervision during their time in the home. They did, however, state that this matter was being addressed and that supervision sessions were being arranged to meet their needs. The registered manager produced evidence to show that he has arranged supervisions in the future and that he has been stressing the importance of this to staff and urging them to start this process. There was evidence of some supervisions having taken place although, overall, there was still a great shortage in the amount having been provided. Most, but not all, staff felt they were well supported in the home which was also the view of staff surveys received. A tour of the premises found it a safe environment for the accommodation of people staying there. An examination of health and safety documents held by the home found that full fire procedures, utilities checks and checks of equipment were being carried out for the safety of its users and staff. At the time of the visit the one exception was that the health and safety audit could not be located and the relevant member of staff was on leave so this could not Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 23 be verified. However, the registered manager agreed to forward this documentation to us subsequently. An examination of training documents showed that there is a routine training for staff in relevant subjects concerning health and safety including moving and handling, first aid and food hygiene. A review of evidence has found that no issue relating to health and safety which has required action to be undertaken. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 24 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 2 X 2 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 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement Timescale for action 01/12/09 2. OP3 14 The home must review its Statement of Purpose to consider whether re-registration is required in order to reflect its current accommodation of people with dementia. The home must improve the 01/12/09 assessment procedures so that inappropriate admissions are avoided. The home must instigate a full 01/12/09 programme of formal supervision for staff so they are fully supported in their work. The home must instigate a full 01/12/09 training plan for staff so that they are kept up to date and developed in their work. 3. OP36 18 4. OP30 18 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 Good Practice Recommendations DS0000036720.V375408.R01.S.doc Version 5.2 Page 26 Mountview Community Support Centre 1. Standard OP16 The recording of complaints would be improved by listing them separately so that any pattern can be identified. Mountview Community Support Centre DS0000036720.V375408.R01.S.doc Version 5.2 Page 27 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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