Inspection on 11/10/05 for Dean Wood Manor

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Dean Wood Manor 26/02/09

Dean Wood Manor 22/05/08

Dean Wood Manor 22/08/07

Dean Wood Manor 20/12/06

Dean Wood Manor 11/05/06

Dean Wood Manor 27/02/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dean Wood Manor Spring Road Orrell Wigan Greater Manchester WN5 0JH Lead Inspector Lindsey Withers Unannounced Inspection 11th October 2005 09:00 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 Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 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. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dean Wood Manor Address Spring Road Orrell Wigan Greater Manchester WN5 0JH 01942 223982 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) www.mimosahealthcare.com Mimosa Health Care Limited Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (43), Physical disability (1), Physical disability of places over 65 years of age (8) Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 50 service users, to include: Up to 43 service users in the category of OP (over 65 years of age) Up to 8 service users in the category of PD(E) (over 65 years of age) plus one service user in the category of PD (named service user) The service should employ a suitably qualified and experienced Manager who is registered by the CSCI. The Home must be appropriately staffed at all times. The numbers and skills mix of the staff must meet the needs of service users. N/A – new provider 2. 3. Date of last inspection Brief Description of the Service: Dean Wood Manor is located off the main Orrell to Standish road. The premises comprising Dean Wood Manor are based around an original Grade II listed building that has been extended to provide accommodation to a total of 50 people. The gardens surrounding the home are extensive and wellpresented. Car parking for visitors is good. The registration categories (i.e. the groups of people who can be admitted) are under review, but at the time of this inspection a total of 8 people under the age of 65 and one person over the age of 65 with a physical disability could be admitted, and 43 elderly people. All residents living at Dean Wood Manor receive nursing care. Formerly known as Orrell Hall, Dean Wood Manor is now part of the Mimosa group of homes. The Mimosa philosophy is “Where people matter”. The stated aim is to provide all residents with the kind of individual care they need, whilst maintaining their independence, dignity and freedom of choice. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mimosa Healthcare purchased the home formerly known as “Orrell Hall” in July 2005. The home is now called “Dean Wood Manor” and this was its first inspection. The inspection was unannounced. Representatives from Mimosa – Barbara Cotman and Mark Butler – were on site at the time of the inspection and assisted the new Manager, Noble Sebastian, with the inspection process. (The registration process for Mr. Sebastian was in progress with the CSCI at the time of this inspection.) The inspection took place over 7 hours and involved looking at the records that the home has to keep to show that it is being run properly, looking around the home, and talking at length to five residents and one member of staff. Other members of staff and residents were spoken to over the course of the inspection. Information provided in reports and letters to the CSCI has been taking into consideration in the preparation of this report. Pharmacy Inspector, Stephanie West, made her inspection of medication management at the home. Her comments, requirements and recommendations are included within this report. What the service does well: What has improved since the last inspection? This was the home’s first inspection under the new ownership. Improvements will be assessed at the next inspection. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 6 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. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 7 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 Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Not assessed on this occasion. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10. Residents are treated with courtesy. They can be assured that they will be treated with respect and dignity, and that their right to privacy will be upheld. Procedures were in place to facilitate the safe administration of medicines but medication record keeping must be improved to ensure residents are given medicines as prescribed. EVIDENCE: In conversations with the Inspector, residents spoke about how they were helped by staff during the day and night. One resident spoke about being helped to get washed and dressed. For another resident, it had been important that she had a cardigan with a zip rather than buttons, because she could manage this alone. Female residents spoke about clothes they liked to wear, and their preference for cosmetics, fragrance or toiletries, and whether they liked to carry a handbag or not. A number of residents liked to walk around the home – which they could do in safety – stopping off for a short rest at one of the many seating areas. Staff were seen to be walking with residents, or sitting down and having conversations. When staff passed by, they acknowledged the residents: they did not pass by without speaking. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 10 Residents were called by different forms of address, from the more formal Mr. or Mrs. to familiar nicknames, according to the preference of the resident. Staff were seen to knock on doors of bedrooms or bathrooms before entering. From observations it was seen that residents were able to express their individuality. Members of staff were seen to be encouraging residents to maintain their independence, whether this was supervising someone carrying their own cup of tea or accompanying someone along a corridor. Residents’ self-worth was being promoted. Rather than assume they knew the answer, staff asked questions of the residents – did he or she like milk in their tea, was this where he or she wanted to sit. Qualified nurses manage all residents’ medication except the application of some prescribed creams, which is delegated to care staff. The medication records were generally up-to-date but some indicated administration of medicines that had not been given and there was on occasion lack of clarity this was particularly evident where doses had changed ‘mid-prescription’ and must be addressed. Homely remedies were used within the home but administration was not from a dedicated stock. The medication storage was generally orderly and medication was securely stored. A dedicated refrigerator was available but the actual temperature was not monitored. The ‘fridge was observed to be ‘iced-up’ and in need of defrosting. It is recommended that the ‘fridge be defrosted and temperature monitored. Eye drops were not dated on first opening, this is recommended to help ensure that they are not used for extended periods. The medication policies need to be updated to reflect the changes in the management of unwanted medication. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Not assessed on this occasion. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: Not assessed on this occasion. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. Residents living at Dean Wood Manor can be sure they will be living in safe, comfortable, clean, and well-maintained surroundings. EVIDENCE: Since taking over the home, Mimosa Healthcare has begun a rolling programme of redecoration of the whole of the premises. New furniture has been purchased for communal areas and for private bedrooms, and more was scheduled to be delivered. Carpets and other flooring were in the process of being replaced. Some windows and doors had been replaced. Some internal doors were scheduled to be replaced. Curtains and other window dressings were being replaced. All redecoration was to a good standard. New furnishings and fabrics were of good quality. One resident said she was very pleased with the “lovely” new piece of furniture that had been bought for her room. Another resident was waiting to move to a Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 14 ground floor room that had been redecorated and refurnished in a style that she said was “gorgeous”. The grounds that surround the home are attractive and well-maintained. The pond has been fenced in, making this area safer for residents. Mimosa Healthcare has been working closely with the local fire service to ensure all aspects of fire safety are achieved. The home was clean and fresh throughout, and was warm but well-ventilated. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Notwithstanding the two minor shortfalls that were identified at this inspection, the staff recruitment and selection process is good. The home has sufficient staff on duty at all times, including extra staff at busy times. Staff have a good range of skills and experience that bring benefits to residents, and receive training appropriate to their area of work. Residents can be assured, therefore, they will be properly cared for by competent people who are employed in sufficient numbers. EVIDENCE: The staff rota was looked at for the week of the inspection. The rota was easy to read and changes had been clearly recorded. There is a good ratio of staff to resident that is above the minimum recommended. This is because of the dependency levels of the residents and because staff are undertaking lots of training. The peak periods of activity at the home are around 7.30 in the morning and 9.30 at night (i.e. the times at which residents may be getting up or going to bed). Additional staff are on duty at these times. Because all residents at Dean Wood Manor receive nursing care, a registered nurse is on duty at all times. The new Manager is dual registered as a Registered Mental Nurse (RMN) and Registered General Nurse (RGN). When he is off duty, another RMN is on duty. Other nurses are Registered General Nurses. The staff complement also includes Team Leaders, Senior Carers, and Carers. The Activity Co-ordinator position was vacant at the time of the inspection, but interviews had taken place and a person had been selected, subject to satisfactory references and checks with the Criminal Records Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 16 Bureau. (Care staff are providing some activities on a group or one-to-one basis until the Activities Co-ordinator post is filled.) Ancillary staff include a handyman/gardener, a housekeeper, and laundry, domestic, and kitchen assistants. The cooks are employed by an external catering company. The nurses employed at Dean Wood Manor are registered with the Nursing and Midwifery Council (NMC) and have a range of skills and experience that bring benefits to the residents. A nurse’s area of expertise is valued; links with other health professionals are forged – for example, with the tissue viability nurse – so that residents’ needs are recognised and met. 65 of care staff have achieved National Vocational Qualification (NVQ) level 2 in care (or equivalent). Those NVQs that were in progress via Wigan Social Services were to continue. Carers yet to commence their NVQ training would do this through Mimosa’s own training and development department. The two team leaders have had considerable experience in care and have training in a range of subjects that ensures they are competent to manage care staff, and to identify care needs in residents. The team leaders have a good communication system that ensures information is passed from one to the other. Four staff personal files were looked at. These were complete and up to date with two exceptions: one person had not had a Criminal Record Bureau check secured by Mimosa - the check for this person had been done by a previous employer and was not, therefore, current; the job description for one person was not on file and, in conversation, it was not clear that the person had received one. Ms. Cotman and the Manager agreed to deal with these issues immediately. At the time of this inspection, staff had not been informed about the code of conduct and practice set by the General Social Care Council. Ms. Cotman was aware that this awareness was lacking and confirmed that the Mimosa Training Department would be addressing this shortfall in the future. She explained that priority had been given to ensuring all staff had received mandatory training (moving and handling, fire safety, etc.) plus additional training (protection of vulnerable adults, care practice, etc.) so that they were competent to do the work that they were employed to do. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36, and 38. Emphasis is placed on safe working practices so that the health, safety and welfare of residents and staff is promoted and maintained. Staff are supervised on a day to day basis but formal supervision has yet to commence. Formal supervision will ensure staff are provided with the support they need to do their jobs and get maximum career development. The home does not take responsibility for residents’ personal money; this lies with the resident’s family or other supporter. The home has a system for looking at the quality of service that it provides. More work needs to be done to include residents in the quality assurance and quality monitoring process. EVIDENCE: The home has an annual development plan that sets out the aims and outcomes for residents. This fits in with the Mimosa philosophy: “Where people matter”. The plan has been discussed in meetings with the CSCI and was not looked at during the inspection. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 18 Since taking over the home, Mimosa has introduced regular staff meetings: the Manager oversees separate meetings for nursing staff and care staff. Staff attendance at the meetings is reported to have been good. The Mimosa auditing system has been introduced. Audits of the service provided by the home are carried out internally by the Manager, and separately – on an unannounced basis - by a representative from Mimosa’s head office, and involve staff and residents. Copies of audit documentation prepared by head office staff are sent to the CSCI. Quarterly meetings with residents and their relatives are being planned but none had taken place at the time of this inspection. The Manager said that relatives had been approaching him to speak to him about a variety of issues and, from these conversations, he felt that relatives were generally pleased with the Mimosa approach to care. A formal survey of the care will be conducted once the home has become established as Dean Wood Manor, and when all the refurbishment is complete. Policies and procedures were not examined on this occasion. No money is held on behalf of residents at the home. Service users’ families (or other supporter) take responsibility for all financial matters. Under the home’s keyworker system, the resident’s main carer ( i.e. the “keyworker”) will be responsible for advising families of the resident’s needs, for example, new items of clothing, additional toiletries, etc. The schedule for staff supervision had not been completed at the time of this inspection. The Minutes of a staff meeting, however, showed that the Manager had informed staff that he would be carrying out observational supervision over a three month period, after which time formal supervision sessions would begin. Mentorship for nurses is provided by the Manager and two other nurses. Mentorship for nurses is also provided by headquarters staff, many of whom have a background in nursing. Since taking over the home, Mimosa has placed considerable emphasis on ensuring safe working practice. This has been overseen by the organisation’s health and safety specialist. Staff have received training appropriate to their area of work so that they are working safely. Some members of staff (including those who work during the night) have been identified as “the appointed person” with responsibility for health and safety, fire, moving and handling, or first aid. Additional certificated training has been scheduled for these individuals. Systems have been put in place so that the health and safety of residents and staff is assured. Work has been undertaken to ensure that the home is compliant with current legislation, most notably in relation to fire safety. Mimosa’s policy on safe working practice has been introduced, and staff were seen to be working in a way that kept them and the residents safe. Risk assessments have been carried out, the best example being the fencing-in of the pond, as residents were at risk of falling in. A new accident reporting system has been introduced. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 19 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x x x x STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 2 x 3 Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 13 Requirement The provider must ensure that the medication policies and procedures are reviewed and implemented The provider must ensure that homely remedies are only administered from a dedicated supply. The provider must ensure that all medication records including those for the administration; the use of ‘when required’ medicines, and for the disposal of unwanted medicines are complete, clear, accurate and up-to-date. Staff must be screened by Mimosa via the Criminal Records Bureau before commencing in post. Disclosure records from previous employers are not acceptable. Timescale for action 05/12/05 2 OP9 13 05/12/05 3 OP9 13 05/12/05 1 OP29 19 01/11/05 Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 1 2 3 Refer to Standard OP9 OP9 OP9 OP9 OP9 OP9 OP29 OP33 OP36 Good Practice Recommendations Nurse delegation to competent staff is evidenced, and their responsibilities are recorded. Handwritten additions or alterations to the MAR should be signed, independently checked and countersigned. Arrangements for the supply of leave medication should be documented. The ‘fridge should be defrosted and the temperature recorded. Eye drops should be dated on first opening Consideration should be given to performing a regular recorded managers MAR audit. It is good practice when varying a contract to provide a new job description. As soon as possible, meetings with residents and relatives should begin. The planned timetable for the commencement of formal staff supervision should be adhered to. Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 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 Dean Wood Manor DS0000064122.V256076.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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