Inspection on 18/10/07 for Mahogany Care Home

This inspection was carried out on 18th October 2007.

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

Mahogany Care Home 26/11/09

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mahogany Care Home Marsden Street Newtown Wigan Lancashire WN5 0TS Lead Inspector Janet Ranson Unannounced Inspection 10:30 18 October 2007 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 Mahogany Care Home DS0000070000.V345011.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. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mahogany Care Home Address Marsden Street Newtown Wigan Lancashire WN5 0TS 01942 820800 01942 492111 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) None Mimosa Healthcare (No4) Limited Mrs Kathleen Barnett Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 51 2. Date of last inspection Brief Description of the Service: Mahogany Care Home is a purpose built, single storied building. It provides care with nursing for older people in a well maintained home. The majority of rooms are for single occupancy but there are also a small number of shared rooms. All the bedrooms have en-suite facilities. There is off road parking and pleasant gardens to sit in the better weather. The home is privately owned by Mimosa Healthcare Ltd. The company have homes located in other parts of the country. The home is ideally situated close to a shopping area and local transport links. Fees for accommodation at the home range from £322. 65 to £600.00 per week. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by us (the Commission for Social Care Inspection) in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 6 hours on Thursday 18th 2007. During the course of the site visit we spent time talking to; • • • • • • • • residents visitors the manager, deputy manager, senior care, the administrator chef, the activities organiser We did this to find out their views of the home. Before the site visit we sent out residents and relatives surveys and some of the comments we received have been included in our report. We also examined a selection of residents and staff files and looked around the building. We saw evidence that the management and staff continued to work hard to develop and improve the service. What the service does well: We could see the home provides a warm and welcoming atmosphere. It is well maintained with a high standard of décor, furnishings and hygiene. The garden is especially pleasant and inviting with seating, raised flowerbeds and a small “allotment.” A relative responded in the survey, “This is a quality care home. They treat each person as an individual responding to their care and needs.” Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 6 Another responded to the question “What do you feel the care home does well?” “Makes the home feels like home, staff are approachable to discuss concerns if any. Staff are very helpful and friendly.” We saw that the residents were safeguarded by the recruitment procedures. We saw that staff records were well kept and included all the important checks to help protect people living at the home. Staff told us that there was a good programme of training available. We saw the residents were relaxed and willing to talk about their experiences and proud of the cards they are making to raise funds for the home. We also saw that the residents benefit from social stimulation and a programme of activities. We saw that visitors were made welcome when they arrived at the home. We thought the welcome to Mahogany care home card that was given to each person who had started to live at the home, was a particularly nice touch. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mahogany Care Home DS0000070000.V345011.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 Mahogany Care Home DS0000070000.V345011.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): 1 & 3 (Standard 6 intermediate care is not provided at this home.) Quality in this outcome area is good. The home’s system of assessment reflected individual preferences and social requirements. This meant that the home could be certain they could meet the prospective resident’s diverse needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at range of care records for those residents who had been assessed as requiring the kind of care provided at Mahogany. We could see they all contained pre admission assessments. The manager told us that she undertook assessments of all prospective residents prior to admission, along with a senior member of staff. We thought the assessments were well documented. Identifying personal preferences and social abilities as Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 10 well as personal and nursing care needs. We could see that the person or their representative had been involved in the assessment. The manager told us the home would only admit people in a planned manner. That is with a full assessment from the social worker, a visit to the prospective residents current place and where ever possible for the person to spend some time at Mahogany so that they could see what was offered. This means that the home could be certain they could meet the individual needs. A resident told us in the survey that (they) “came down and saw the place for themselves then somebody from the home came to do an assessment, but did not receive any information.” We spoke with another visitor who clearly remembered visiting the home on behalf of his relative and having a “brochure” given to him at this time. Mahogany Care Home DS0000070000.V345011.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): 7, 8, 9,10 & 11 Quality in this outcome area is good. The resident’s individual health and social requirements are clearly identified and documented in a care plan. The plans provide the carers with action to be taken to provide appropriate care on a day-to-day basis. This means that the resident’s benefit from the individual care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at a selection of care plans. We could see that each identified need had a plan of care, which included • • • • • personal hygiene continence issues mobility and dexterity tissue viability moving and handling assessment DS0000070000.V345011.R01.S.doc Version 5.2 Page 12 Mahogany Care Home • nutrition with the use of universal screening tool. We could see that risks associated with daily living had also been identified and clearly set out. Social history and previous hobbies or activities were recorded to provide carers with a greater understanding and a wider picture of the resident’s abilities. The records showed us that visits from the chiropodist, physiotherapist, general practitioner, opticians and other healthcare professionals were all noted within the individual care file. We thought the care plans were detailed, evaluated and placed the person at the centre of the care so their direct wishes and preferences were clearly documented. We were also able to track the outcomes of certain actions to a satisfactory conclusion. The manager told us this was a new care planning system. Each section was printed on different coloured paper to differentiate between the sections. At all times and in all areas of the home we could see and hear carers treating the resident’s and their visitors with the greatest respect. We could see carers using good interpersonal skills with the residents who responded in a positive way. The resident’s were generally well groomed, clean and tidy. Visitors at the front door were greeted informally and made welcome to the home. A visiting relative told us that he visited the home most days and he was always made to feel welcome and involved in his relatives care. He also spoke highly of the staff, saying they were “patient, considerate and very caring, nothing was too much trouble.” We looked at a selection of residents’ medication administration records (MAR). We could see from the records that the residents were getting their medicines as prescribed by their general practitioner. We could see that each unit had their own medication storage space. The medication was administered from a monitored dosage system under contract to a local pharmacist. We were told that the senior staff, who are responsible for giving the residents their medication, had all received the appropriate training to do this safely. We could see that part of the homes recording system was to obtain the resident’s written instructions concerning their end of life care. The manager told us this was company policy. The form included any instructions concerning none medical intervention. We could not always tell from the record (where it Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 13 had been completed) that any instructions were the resident’s actual implied wish, and as such may have doubtful legal status. We thought that training in the new Mental Capacity Act could help in this matter. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. The resident’s benefit from a wide range of activities, trips out of the building and contact with the local community. The resident’s dietary needs are well catered for with a balanced and varied choice of food available to meet individual tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We could see that the home’s assessment procedures document the prospective resident’s previous lifestyle, activities, hobbies and religion. We could see that one person had told the carers that she “liked to wear make up and perfume and go to church with a friend.” We spoke with the activities organiser who works full time at the home. She explained about the various activities she provides each day. We were Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 15 impressed by her enthusiasm. We were told that card making was popular and we were shown examples that had been made by the resident’s to sell to visitors and friends. We were told that the money went towards trips out and other activities. We could see photographs displayed around the home showing the residents enjoying themselves on trips and at parties. A resident told us that she had “no regrets about giving up her home and living at Mahogany except that she should have done it earlier.” A resident told us that she went to bed when she wanted to and got up when she felt like it. Throughout the home we could see the residents in their rooms and in the communal areas. In one lounge the residents were enjoying light music. Many of the bedrooms had personal televisions. There were lots of people visiting the home. We were told that the residents could attend a monthly meeting with the activities organiser and the chef. At the meeting we were told that the residents could discuss where they wanted to visit, what they wanted to do and the content of the menu. Minutes were taken and made available for those people who had not been able to attend. We could see there were 2 dining rooms both of which were nicely presented. The tables were laid with tablecloths, napkins and condiments. There were also aids to assist people to eat independently. We could see that some people preferred a beaker to drink from and others a china cup and saucer. One person told us she had always preferred a china cup and saucer when she had lived in her own home. We spoke with the chef and looked at the menus. The weekly menu was displayed in the units. It showed us that there were options and alternatives to each meal. The content of the meals looked well balanced and nutritious. The chef told us that he remains in contact with the residents by serving the main meal of the day. He demonstrated his knowledge of special diets and those residents who require different consistencies of food. Some vegetables including tomatoes, runner beans and herbs are grown in the central garden by the residents. During the inspection we could see the cook picking green beans for the evening meal. The residents told us there are plans to extend the type of vegetables next season. This means the residents take an active interest in their diet, benefit from the freshness of the vegetables as well as getting exercise from gardening. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Residents and relatives felt comfortable in raising any concerns they may have which means that they are listened to, and responded to. The recruitment and selection process makes sure the residents are protected from potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We could see the home’s complaint procedure was displayed in the entrance hallway and included in the “welcome pack.” Those people who spoke to us said they would speak to the manager or the senior person in charge if they had any concerns or complaints. Some comments in the surveys told us that people knew how to make a complaint. We received comments such as: • • • “Never had cause to complain.” “No complaints it is fine as it is.” “Couldn’t find a fault.” Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 17 We could see that the manager was available and known to the residents and visitors alike. A visitor told us that the manager always seemed to have time to speak to people. We were told that the staff have received training on how to recognise abusive actions and how to report such incidents. This is part of the induction and National Vocational Qualification (NVQ) studies. There have been no complaints made directly to the commission neither has there been any safeguarding incidents. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 26 Quality in this outcome area is excellent. The residents are provided with a welcoming, warm and safe home in which to live. The garden is fully accessible, providing the residents with a pleasant outlook. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We could see that the rooms provided a high standard of comfort and style. The bedrooms were bright, comfortable and personalised with pictures, photographs and ornaments. This gave them a homely appearance. We were told that the bedrooms continue to be refurbished and decorated. All the bedrooms have en-suite facilities. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 19 One resident told us her family had decorated her room whilst she was in hospital. Although she said it was a bit small (when compared with her home) she told us it felt like home with her own bedding, photos, art work and ornaments. The living and dining areas in both units provided pleasant seating areas. They were clean, tidy and had a calm and relaxed atmosphere. We could see there was a variety of armchairs for the resident’s and their visitor’s comfort. We could see there were aids and adaptations to meet with individual resident’s needs throughout the home. We could see that the grounds were well maintained and tidy giving a pleasant aspect from all areas of the home. The central garden was fully accessible including for those people with limited mobility. A resident told us that they particularly enjoyed the raised flowerbeds and newly installed water feature. We were also told that the gardens are well used in the better weather. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. The resident’s benefit from a team of staff who are trained and competent to carry out their duties. The residents are protected from potential abuse by the robust recruitment and selection process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We could see that there were staff in numbers and with the skills to meet the residents diverse needs, on duty throughout the day. Staffing rotas were available showing who was on duty at anyone time. We spoke with staff who had worked at the home from between 17 and 7 years. We thought this must provide the residents with continuity. We were impressed with the way the staff worked together and the way they conducted themselves. Each person who spoke with us said they enjoyed working the home. A visitor wrote in response to the question, Do the care staff have the right skills and experience to look after the people properly? “They can look after me anytime, they are great.” Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 21 We could see that the staff were up to date with all aspects of health and safety training. We were told other mandatory training is provided by the company through an external training agency. Records were available concerning individual training needs and achievements. The manager told us that NVQ training to levels 2 and 3 is supported by the company, and there is an intention to encourage more carers to achieve level 3 in care. We checked a selection of staff files. We saw that they contained the required records and showed that the home had taken up references and had made checks with the Criminal Records Bureau (CRB) and with Protection of Vulnerable Adults (POVA) registers before the person began to work unsupervised at the home. This means that the residents are safe and protected from potential harm. We could see that the staff files were well ordered and securely held by the administrator. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is excellent. The manager of the home has the skills, experience and qualifications to run the home in the resident’s best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw that the manager has considerable knowledge with seventeen years experience of running a care service for older people. The manager told us that she has completed the NVQ Level 4 in Management. This demonstrated to people visiting the home that she had the necessary skills qualifications and experience needed to manage a care home. Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 23 We could see that the manager was supported in her role by a team of qualified and experienced senior staff. We saw that the home had policies and procedures that were kept under review by either the staff or head office. This made sure that staff were able to access the most up to date information regarding care practices. We saw the home had a system to protect the financial interests for those residents who were no longer able to deal with their own money. Satisfactory records with receipts covering all expenses were retained for auditing and inspection purposes. We saw that the manager operated an open door policy and residents and staff had access to senior staff at all times. Staff told us that the manager was always ready to listen to concerns and answer questions. They told us that the views and opinions of both residents and staff are listened to, and valued. We could see the care plans and risk assessments were up to date and regularly reviewed and evaluated. We were told the company uses the services of an external quality assurance organisation. The organisation carries out an annual audit of policies and procedures as well as sending out satisfaction questionnaires to the residents, their relatives and the staff. There was evidence that comments contained within the surveys were acted up wherever possible. The residents also have meetings where they can become involved in the running of the home. We know that the registered provider remains in contact with the home. The reports of regulation 26 visits made to the home by the registered provider or their representative were available for inspection. We saw no hazards to health during the inspection. The health, safety and welfare are further ensured by the systems in place to report any accidents and incidents. Mahogany Care Home DS0000070000.V345011.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X X X X 4 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 4 X 3 X 3 X X 3 Mahogany Care Home DS0000070000.V345011.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. 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 Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mahogany Care Home DS0000070000.V345011.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!