Inspection on 01/07/08 for Mandale House Care Home

This inspection was carried out on 1st July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mandale House Care Home 23/05/07

Mandale House Care Home 09/05/06

Mandale House Care Home 23/01/06

Mandale House Care Home 12/09/05

Mandale House Care Home 20/10/04

Mandale House Care Home 12/07/04

Similar services:

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Turret Villa Retirement Home

Moor House

Mendip House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Mandale House Care Home 136 Acklam Road Thornaby Stockton-on-Tees TS17 7JR Lead Inspector Jackie Herring Key Unannounced Inspection 1st July 2008 09:30 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 Mandale House Care Home DS0000000185.V367493.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. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mandale House Care Home Address 136 Acklam Road Thornaby Stockton-on-Tees TS17 7JR 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) 01642 674007 01642 674007 T L Care Ltd Manager post vacant Care Home 57 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (27) of places Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual who is under the age category can be admitted to the home on a permanent basis. 23rd May 2007 Date of last inspection Brief Description of the Service: Mandale House is a 57-bedded care home providing personal care for older and older people with dementia. 55 of the bedrooms are single with ensuite facilities and there is one double room with ensuite facilities. The home operates two dedicated units, 30 beds within the upstairs unit for older people with dementia and 27 beds on the ground floor for older people who have personal care needs. Mandale House is situated in reasonable proximity to a local park and public house. Public transport is in easy reach and the home is on a main traffic route. The fees for living at Mandale House range from £355 per week £389 per week depending on need and the local authority. Mandale House Care Home DS0000000185.V367493.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 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced Key Inspection of Mandale House; as such all of the key standards related to older people were looked at. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted in one inspection day by two inspectors, a total of ten hours. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. A number of surveys from people who live at the home and one from a relative were also received. Time was spent talking to people who use the service, relatives and staff. Time was also spent walking around the home, observing interactions and generally finding out what Mandale House was like for the people who live there and staff. Discussion took place following the inspection with the operations manager. The manager has completed the Annual Quality Assurance Assessment (AQAA), the services self-assessment of how well they think they are meeting standards. This was received prior to the inspection and some of information has been reflected within the report to support the judgements made. What the service does well: Mandale House has a team of staff who have been in post for a substantial number of years and are well experienced, as a result the home run’s smoothly on a day to day basis. Mandale House has a warm, relaxed and friendly atmosphere; the home is generally well maintained. The people living at the home are happy and generally content with the service provided and the care they receive. They said, “If I have any problems with my health the staff arrange an appointment with the doctor”. “The girls always look after me”. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 6 Relatives said, “Very communicative staff, always happy to help and keep us informed”. “Very caring staff, all mum’s/dad’s needs are met”. “All residents appear to be treat as individual and the care they receive is the care they need”. A member of staff said, “The service helps to keep the residents safe and well, making sue everyone understands the needs and support to the residents”. Another survey stated, “The staff are all trained and promote independence and dignity to the service users at all times”. The staff are very well trained, with 99 of them trained to NVQ Level 2 or above, which is commendable. What has improved since the last inspection? What they could do better: There needs to be a manager in post who will give the home the leadership and development that is needed. The work that has been progressing in regard to the care records should continue. A number of improvements are needed to the environment. The most significant area is the malodour problem in the first floor lounge. Quality assurance systems need to be developed further and the required Regulation 26 visits need to take place on a monthly basis. The policies and procedures need to be reviewed further to ensure they are reflective of the service and give the information needed to ensure the safety, wellbeing and welfare of people in the home. Staffing levels need to remain under review to ensure that they are sufficient to meet the needs of people living at the home. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 7 Staff induction needs to be in line with the Skills for Care Common Induction Standards. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mandale House Care Home DS0000000185.V367493.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 Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 3 & 6 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People have their needs assessed before being admitted to the home and they were assured those needs would be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA detailed the admission process for anybody who wanted to live at Mandale House. It stated, “Residents are given a full assessment prior to admission to the home, carried out by the home manager, assistant manager or unit manager to ensure that the home can fully meet the needs of the prospective resident. Up to date assessments/ copies of care plans are obtained from the previous care provider/social worker”. It also details that residents are welcome to try our service before committing themselves to long-term care. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 10 Three sets of records of people living at the home were looked at, one was the most person admitted to the home, another was someone who had lived at the home for six months and another was someone who had been living at the home for some considerably time. There was a pre assessment completed by a key member of the senior staff and also a copy of the care management assessment and care plans. There was also evidence of review ensuring that people were happy and that their care needs were being met. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 7, 8, 9 & 10 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People, who could say, are happy with the way in which care is delivered by staff. Some of the records detailing how health and personal care is to be delivered would benefit from having more detail and information and further needs specific care plans would be helpful. The system for managing medication is good and only staff who have received the appropriate training have any involvement with medication. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The same three records were looked at in more detail to see if ongoing assessments were being carried out, were up to date and that a range of supporting care plans were in place. In two of the three records, the assessment of need had been completed; there was more detail in one than the other. Needs had been identified, however it was advised that the assessment should contain more detailed information about the individual person and their lifestyle not just a focus on problem areas. In the third record looked at the assessment had been partially completed. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 12 In all three records looked at, care plans that details the support needed were in place for some of the needs identified but not all. A range of risk assessments are in place, however there is the need to ensure that all risks are identified for examples falls. Evaluations of care are taking place but these are not value based and do not demonstrate whether the care provided is being effective or not. This was feedback to one of the unit managers who said that they are continuing to develop the assessments and care plans and thinks that some additional training would be helpful. There was good information about the involvement of GP’s, district nurses and hospital appointments. The systems for medications were checked storage, recording and administration. Medications were appropriately stored, staff spoken to were aware of the correct procedures to follow regarding safe handling. The medication administration records of four people living at the home were checked all of these were satisfactory with no gaps errors or emissions. The problem identified since the last inspection in relation to the management of a controlled medication elixir has been resolved staff are aware of the procedures to follow. The policy and procedure for the management of medication was not available within the files looked at. Surveys from people who live at the home contained the following information; “If I have any problems with my health the staff arrange an appointment with the doctor”. “The girls always look after me”. Relative surveys stated, “Very communicative staff, always happy to help and keep us informed”. “Very caring staff, all mum’s/dad’s needs are met”. “All residents appear to be treat as individual and the care they receive is the care they need”. In one of the staff survey, of what the service does well a member of staff said, “The service helps to keep the residents safe and well, making sue everyone understands the needs and support to the residents”. Another survey stated, “The staff are all trained and promote independence and dignity to the service users at all times”. Mandale House Care Home DS0000000185.V367493.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 12, 13, 14 and 15 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who use the service have some opportunity to take part in activities, although this could be developed further. They are supported to live in a flexible environment where there is choice of routines and independence. People are satisfied with the meals provided. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People who live at the home, their relatives and staff thought that the social aspect of care within the home could be improved. They said, “Feel reasonably happy with homes services, food is good, staff are caring, would like the opportunity though to have more trips out, also not enough activities”. “Staff look after us well, food provided is good, not enough to do, would like more trips out”. Relatives of people living at Mandale House also thought that the activities could be improved. Two of the relatives spoken to both felt that overall the care was good. However they both described that in their opinion there was not enough activities occurring for the people. Staff also said about what the service could do better, “The service could help to stimulate the resident who always seem to do the same thing day after day. More entertainment to get the residents to enjoy themselves”. It was confirmed Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 14 that a recent staff appointment had been to develop activities further. There had been a recent trip to Redcar that people enjoyed. Through discussion with staff, it was confirmed that there is no actual budget for activities, social and recreational events. This money has to be raised by the staff through fundraising. Staff who were spoken to confirmed that people were able to practise their religion if they so wished. There is currently visiting clergy for those who want to be involved and other arrangements would be put into place should the need arise. A staff survey stated, “We have had quite a lot of training to help us to understand their need and respect their faith”. Relative’s surveys stated, “Very supportive and friendly staff”. People are able to visit the home when they want to. Visitors were observed during the inspection and they confirmed that they regularly visited and sometimes took their loved ones out. The kitchen was visited and a good levels of frozen, dried, tinned foods also good stocks of fresh fruit and vegetables were seen. Menus, which were seen, did not state an alternative choice of food for main meals each day. It was however clear that alternative meals were available and at lunch-time people were observed to be having either a full cooked meal, sandwiches or poached egg. Discussion took place about introducing and second choice on the menu and about making the actual menu more accessible to people living at the home. It was agreed that this would be looked at. Observation during the inspection visit showed that there was a relaxed and friendly atmosphere in the home. Kind and caring interactions were seen and there was light chatter and laughter in evidence. A member of staff spoken to said, “We try to encourage independence and also friendships between the residents”. Mandale House Care Home DS0000000185.V367493.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 16 & 18 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who live at the home are generally confident their complaints would be listened to, taken seriously and acted upon, although the actual procedure needs updating. People who live at the home are protected from abuse by the home’s policies and procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA stated, “Any complaint that is received is recorded in our complaints book. A full and robust investigation is carried out and a report is sent to our Operations Manager regarding the outcome”. The AQAA detailed there had been no complaints since the last. The complaints book was looked at and the last recorded complaint was May 2006. This was discussed with the administrator and unit manager who both confirmed this to be the case. There was discussion about concerns and complaints and it was confirmed that systems were in place for dealing with them, but there had not been any. People who were spoken to said that if they had any worried or concerns they would feel happy to raise them with the staff. Staff said they were aware of the complaint procedure and would support people to make complaints if the need arose. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 16 In all but one of the surveys from people who live at the home and their relatives, they were aware of the complaint procedure. One person living at the home said if they were unhappy, “I always go to the person in charge of the shift”. Another person said, “I would speak to the manager”. The training matrix showed that staff had received training on Protection of Vulnerable Adults and No Secrets. In the three staff files looked at there were certificates of attendance for this training in place and it was also recorded on their individual training schedule. Mandale House Care Home DS0000000185.V367493.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 19 and 26 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People living in the home generally live in an environment that is reasonably homely and maintained. However some work identified in this report needs to be carried out to ensure good standards continue to be achieved. We have made this judgement using a range of evidence, including a visit to this service EVIDENCE: A tour of the premises was carried out. Requirements from the last inspection regarding the environment were checked. The patio area has been renewed with wooden decking to a good standard. Bathrooms and shower rooms have been reviewed and there is now an adequate mix of these to meet resident needs. Bedroom en-suite sink units that were damaged have been replaced. The downstairs lounge area was seen and is tastefully furnished and decorated a large screen television has been purchased for here. A bookcase had a good selection of books some large print and a good selection of videos. There was also in this room a large fish tank of tropical fish and a birdcage with two Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 18 finches. The dining room downstairs is also satisfactorily decorated however dining tables here were in need of revarnishing. Dining tables had tablecloths and placemats and condiments a choice of drink is offered with meals. A reality orientation board was displayed in the dining area the date written on this was the 1/6/08 these boards when used must be kept up to date. A number of residents bedrooms on the ground floor were visited the majority of these were homely with lots of personal effects and the rooms were nicely decorated and furnished. In one bedroom, which was identified to the administrator, the back of the wardrobe required repairing. Bathrooms and toilet areas were generally clean and tidy. One bathroom on the ground floor identified to the homes administrator the panelling which boxes in the pipes needs repair also electric wiring to the wall needs to be covered. The homes smoking room was seen and is nicely decorated and furnished and the system of ventilation was satisfactory. A number of bedrooms were seen on the first floor the majority of these were found to be not as homely as those on the ground floor with a lack of personal effects, these bedrooms were also generally well decorated. However one bedroom pointed out to the homes administrator had large cracks to the ceiling, which needed repair. A number of bedroom carpets were malodorous and needed to be industrially cleaned. The lounge area and dining area on this floor are combined and was found to be less homely than the ground floor rooms the carpet here was malodorous and needs to be industrially cleaned. A lounge chair in this room is badly damaged and needs to be replaced. Tablecloths to dining tables are not being used and need to be purchased. The sluicing facility in the sluice room upstairs has been removed and needs to be replaced. Throughout the visit to the home there was no evidence displayed of a weekly activities programme for the residents. A tree in the garden of the home was seen to be encroaching onto the building and needs pruning. The fire exit door upstairs leading down to the kitchen the keypad to the door was not working a member of staff who was in the area said that it had not been working since last Friday. The homes administrator was asked to call out the contractor immediately for quick repair work to be carried out this was done. This work has been completed. The kitchen area was visited this was found to be generally clean and tidy. Cleaning records, food temperature records for here were seen and were being satisfactorily maintained. The first aid box for staff was well stocked. The laundry room was seen and was generally clean and tidy COSHH information was displayed the laundry member of staff was spoken to and she was knowledgeable of the procedures to follow. All of the machines here were working satisfactorily. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 19 Mandale House Care Home DS0000000185.V367493.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): Standards: 27, 28, 29 & 30 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who live at the home have their needs were met by the numbers and skill mix of staff who were trained and competent to care for people who live at the home. People are protected by the home’s recruitment procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People who live at the home were satisfied with the level of care and staffing provided. Staff who were spoken to said that they generally managed with the current staffing of the home. Staff on the ground floor were at times finding it difficult. There are currently three staff for twenty-two people who live on the ground floor unit. The difficulties encountered are in relation to answering the door, the phone continuously ringing, seeing to GP’s and people having to attend for appointments. This often left one staff member to see to the vast majority of the people. Three sets of staff files were looked at and all contained the information needed to show that good recruitment practices are in place. This included application forms with detailed employment history completed, appropriate references and Criminal Record Bureau checks which are completed and returned prior to the first span of duty. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 21 Two members of staff were spoken to one had worked in the home for 8 years the other for 3 years both were knowledgeable of the client group and home procedures and practises in meeting resident needs. Both of the staff members are trained at NVQ level 2. and had completed mandatory training with regular updating. Both members of staff felt the care provided by the home was good. One of the staff surveys contained the following information, “The staff are friendly and approachable and work as a team”. One member of staff spoken to said, “I get really excited about coming to work every day, I really do enjoy it, the moral is really good” One of the relative surveys stated, “All care given is above and beyond their skills and experience, all the residents needs are always met”. The AQAA detailed that 99 of staff are trained to NVQ Level 2 or above, which is commendable. A training matrix was made available which detailed all of the mandatory training as well as some additional service specific training, such as dementia care, although staff thought they needed more of this. It is clear that there is a rolling programme of mandatory training in place. Staff surveys contained the following information, Skills for care Induction is not being carried out. A short induction is being carried out by the organisation’s training person. This does not meet the standards required. Mandale House Care Home DS0000000185.V367493.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): Standards: 31, 33, 35 & 38 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. There is currently no manager in post, which is needed to give the leadership and direction. Policies and procedures are not specific to the service and do not give the guidance needed to fully protect people. Quality assurance is not being fully implemented as a core management tool. Personal allowances are well managed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There has been no registered manager in post for approximately eight months. An interim manager was appointed however was not at the home long and did not complete the registered manager process. Steps are in place to address this and the inspectors were informed that a manager had been appointed and would be commencing employment at the home in the very near future. The Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 23 administrator and staff have done very well to keep the home running as it is. The home does however need a manager to provide the leadership and development required. Staff said, “We have managed due to key staff within the home, but that really good level of support has been missing”. The systems for managing the personal allowances was looked at with the home’s administrator who is responsible for this. It was a well-managed system with detailed records in place and copies of receipts. A sample of personal allowances was looked at, they balances, there were two signatures and records were in order. A relative said, “Mandale House is a very nice and friendly care home. My mum/dad has settled into the home very nicely and I put this down to the caring and loving flings the staff afford her/him”. Regulation 26 visits are not being carried out for some time; the last one available within the home was dated April 2007. This was discussed with the Operations Manager who has agreed to address it. Whilst systems are in place in house to monitor a number of areas such as, the care records, medication and the environment, there has been no actual customer satisfaction or request for feedback about the care and service delivered to people. The AQAA detailed that the full range of maintenance and service of equipment is in place and up to date. A small number of maintenance and service records were looked at. Water temperatures were being recorded weekly, however it was unclear if all baths and showers were being checked, as there was no numbering system in place. The fire alarm was also being tested on a weekly basis. The certificates of servicing looked at were up to date. There was some discussion with regard to the fire drills, as currently the names of staff are listed but it does not detail how effective the drills are or how long they took. Fire door leading to a fire exit would not open on the day of the inspection and had been a problem for a few days. Immediate action was taken to address this. Discussion also took place regarding the need to report this type of issue immediately so that appropriate measures could be taken It is unclear what policies and procedures are in use within the home as two different sets were looked at. One of them was clearly out of date, whilst the other was very generic in nature and it was difficult to find you way around them to find the actual policy or procedure needed. The policies and procedures need to give the staff the guidance necessary to ensure the welfare and wellbeing of the people living at the home, they need to be accessible and relevant to the service. Mandale House Care Home DS0000000185.V367493.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 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 4 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP38 Regulation 13 Requirement There must be an up to date policy and procedures, which are relevant to the service to ensure that staff have the correct information and guidance for the safe handling of medication ensure residents are protected. (This remains outstanding from the last inspection) Timescale for action 31/08/08 2. OP19 OP38 13 3. OP19 23 The fire door to one of the first 01/07/08 floor fire exits must be repaired and there must be a system in place to ensure that faults of this nature are reported immediately. This will ensure the ongoing safety of people living and working in the home. Refurbishment must take place 01/09/08 to several areas of the home: • Dining tables need to be revarnished. • The large crack to the ceiling in one of the first floor bedrooms must be repaired. • The sluice that has been removed must be replaced or advise sought from environmental health DS0000000185.V367493.R01.S.doc Version 5.2 Page 26 Mandale House Care Home regarding the need for this or not, which must be recorded within the home. 4. OP21 23 The panelling to the boxed in pipes must be repaired and the electric wiring to the wall must be covered. The significant malodour problem to the first floor lounge must be addressed, as it is unpleasant and not acceptable for the people living in that unit. 01/08/09 5. OP26 23 01/09/08 6. OP30 18 7. 8. OP31 OP33 8(1) 24/26 Other pockets of malodour problems also need to be addressed. All new care staff who do not 01/09/08 hold an NVQ Level 2 in care must complete the Skills for Care Common Foundation Standards. This will ensure they have the underpinning values and principles of care to enable them to carry out their job role for the benefit of people living at the home. A manager must be appointed 01/09/08 and must complete the process to become registered with CSCI. The quality assurance systems 01/10/08 must continue to be developed further to ensure that the home is being run in the best interests of the residents and that effective audit and management systems are in place. Regulation 26 visits must be conducted and a copy of the report must be available within the home. This will ensure that the service is being monitored and it being managed in the best interests of people living at the home. 9. OP38 13 The policies and procedures DS0000000185.V367493.R01.S.doc 01/10/08 Version 5.2 Page 27 Mandale House Care Home must be further reviewed/updated, must be reflective of the service and must provide people with the information they need to ensure safety, wellbeing and protection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care records should continue to be developed and be more person centred. As a result of developing more detailed assessment there should be a range of care plans in place to detail the care and support provided to people. Evaluations of care should be more informative and give details of the effectiveness of the care plans, showing if they are working or not and if people’s needs are being met. Risk assessment should be completed for risk identified such as falls and corresponding care plans should be in place as determined by the risk assessment. The recreation/social activities programme should be developed in accordance with detailed social and lifestyle assessments to ensure that people have more opportunities for social outlets related to their lifestyle needs. Considerations should be given to reviewing the menu to offer a second like for like choice and to also make the menu’s available to people. Staffing levels should continue to be reviewed on the ground floor area and there must be sufficient staff on duty to fully meet the needs of the people living at the home. Steps should be taken to prune the tree that is encroaching on the building. 2. 3. OP8 OP12 4. 5. OP15 OP27 5. OP19 Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 28 6. OP38 Consideration should be given to ways to improve the environment on the first floor, making it more homely and some of the rooms more personalised. The fire drill records should contain more information that the staff who participated, it must detail the effectiveness of the drill. Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Mandale House Care Home DS0000000185.V367493.R01.S.doc Version 5.2 Page 30 - 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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