Inspection on 12/09/05 for Mandale House Care Home

This inspection was carried out on 12th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 01/07/08

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mandale House Nursing Home 136 Acklam Road Thornaby Stockton-on-Tees TS17 7JR Lead Inspector Jackie Herring Unannounced Inspection 12th September 2005 10:00 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 Mandale House Nursing Home DS0000000185.V248956.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. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mandale House Nursing 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 890050 T L Care Ltd Vacant Care Home 57 Category(ies) of Dementia - over 65 years of age (57) registration, with number of places Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 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. 20th October 2004 Date of last inspection Brief Description of the Service: Mandale House is a 57 bedded care home providing personal care for older people with dementia. 55 of the bedrooms are single with ensuite facilities and there is one double room with ensuite facilities. Mandale House is a two storey purpose built home and operates two units, both for the same category of care. 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. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection and carried out over one inspection day, five hours in total. A tour of the environment was conducted; staff files and residents records were examined; residents and relatives were interviewed as were staff and there was informal discussion with residents, staff and the manager. What the service does well: What has improved since the last inspection? The environment has improved since the last inspection, substantial redecoration has taken place in communal areas, corridors and bedrooms and Mandale House appeared brighter and more airy. A previous severe odour problem has also been overcome. The individual residents records have been fully reviewed and new documentation has been introduced, which has improved on previous documentation. Mandale House Nursing Home DS0000000185.V248956.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. Mandale House Nursing Home DS0000000185.V248956.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 Mandale House Nursing Home DS0000000185.V248956.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): None of these standards were examined during the inspection. EVIDENCE: Mandale House Nursing Home DS0000000185.V248956.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): 7, 8, 10, 11 The assessment and care plans need some additional detail, which sets out fully resident’s health, personal and social care needs. Residents have their privacy needs and rights upheld and are treated with dignity; death is managed with sensitivity and respect. EVIDENCE: Four sets of resident’s records were examined during the inspection, two from each of the units. Through an examination of the records and discussion with the manager, it was acknowledged that substantial progress had been made in regard to the assessment of individual needs and care planning, however further development was needed. The additional developments related to more personal details and preferences being included in the assessment of need and also personalisation and expansion of pre written care plans. Of the records examined, there was no evidence of residents or their relative’s involvement with the assessment of need or care plans. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 10 Details for GP, District Nurse and CPN visits were available within all of the files examined and the staff were very positive about the level of support from CPN’s and district Nurses. During discussion with residents they described the staff as polite and respectful. One resident said, “the staff are nice, good and pleasant people, they listen and are very friendly, I am treated well, there is no doubt at all”. A staff member said “all of the residents are individuals, they have different needs and the routine is very much dependant upon the individual”. Illness and terminal care was discussed with the staff, they said, “this is treated with a lot of dignity and respect, we support the families a lot at these times”. Mandale House Nursing Home DS0000000185.V248956.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): 12, 13, 15 Activities are well managed for residents ensuring social, religious and recreational needs are provided for. Residents where possible are able to control aspects of their lives, their independence and make choices. Meals are provided to a good standard within a suitable environment. EVIDENCE: Mandale House employs an activity person who has developed a weekly activities programme, which is based upon group activities and individual activities. On the day of the inspection, dominoes were being played on the morning and during the afternoon there was a group of residents participating in crafts and making paper mache fruit bowls. During discussion with staff they confirmed that there were activities taking place on a regular basis, some of the activities were taking a small group of residents out, trips to Eden Camp or Redcar, manicure and facial sessions as well as bingo and karaoke. Staff also confirmed that resident’s religious needs were attended to and gave an example of residents receiving Holy Communion. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 12 It was noted within the resident’s documentation that there was a sheet for individual preference, which included hobbies and interests, although this had not been fully completed in all of the files examined. During discussion with one resident he said that where possible he made decisions about his daily life, he said, “Me and another residents don’t go to bed until midnight sometimes, we enjoy sitting and having a couple of cans”. Due to a large number of residents having memory and communication problems, it was possible only to obtained informed views from a very small number of residents. Staff described a very flexible day for the residents at Mandale House and one staff member said, “the routine changes every day, it’s not the same and very much dependant upon the individual residents”. A copy of the menu was made available for examination, which was a fourweek rotational menu. It offered a main meal and an alternative, which was also a cooked meal and the inspector was informed that there was also additional items such as sandwiches available. Residents stated that the meals were good, one resident said, “meals are A1, couldn’t wish for anything better”. Visitors were observed during the inspection, one visitor said that they were always welcomed into the home, that it was a very friendly atmosphere and they were kept updated regarding care of their loved one. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 13 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): 16, 18 Relatives are confident that any complaint would be acted upon appropriately. Robust procedures are in place, which ensure that residents are protected from abuse. EVIDENCE: Relative stated that they were fully aware of the complaints procedure and it was confirmed that the actual procedure was on display in the home. Staff said they were aware of the complaints procedure and would be able to assist a resident or relative to make a complaint should the need arise. One relative said, “if I had any concerns or complaints I would speak to the deputy manager about them”. Staff demonstrated a clear understanding of abuse and were aware of Protection of Vulnerable Adults and whistleblowing, should this be required. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 14 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, 21, 26 Mandale House is generally airy, spacious and clean, with sufficient equipment to meet individual needs. The bathrooms are in need of improved lighting and decorating to make a more homely and inviting environment. EVIDENCE: A number of environmental improvements have been made since the last inspection with the corridors and many of the bedrooms being redecorated. The environment appeared brighter and more airy. The bathrooms and show rooms were in need of attention as there were rather dark and did not appear homely. The shower rooms would also benefit from having shower curtains fitted to enhance privacy and dignity and the wooded lip replaced on the floor of two of the shower rooms. It was also noted that the signage for toilets and bathrooms could be improved. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 15 On the day of the inspection, the home was observed to be generally clean and odour free. The small kitchens on each floor would however benefit from additional cleaning and the past odour problems on the first floor should continue to be monitored. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 16 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, 30 The deployment and number and skill of staff on all shifts is appropriate to ensure that at all times residents are supported by an experienced team of staff. The procedures for the recruitment of staff are robust offering protection to residents. EVIDENCE: During discussion with the manager, residents and staff, it was confirmed that there was sufficient staff on duty to meet the needs of the residents. The skill mix, qualifications and experience of staff was also appropriate and there was always either a supervisor or a senior care workers on duty. One relative said, “the staff are very, very caring, nothing is too much for them”. The training programme was made available for examination and contained detail of all the mandatory training such as fire, health and safety and first aid and also detailed in-house induction, annual appraisals and National Vocational Qualifications. 63 of the staff are trained to NVQ level 2 and 7 of the staff also have NVQ level 3. The staff during discussion believed that the staff team were well trained and well able to meet the needs of the residents within the home. They thought the training was excellent and said that there was always training being made available to them. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 17 Client specific training was discussed, and staff confirmed that they had attended dementia care training. It was thought that additional client specific health care training such as knowledge and understanding of Stroke, Diabetes and Parkinson’s Disease would be advantageous. Staff files were examined and contained the required information. There was discussion about obtaining references as there had been some difficulty with one staff member, in these circumstances it was agreed that a third reference should be sought. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 18 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): 31, The manager’s position is currently vacant. manager, the home is being well run. In the absence of a registered EVIDENCE: There is no registered manager in post at Mandale House, however this position has been advertised. The deputy manager is currently managing the home with input from the organisations Operation’s Manager. Relatives, residents and staff believed the home to be well run and well organised. One relative said, “everything is spot on, it is well organised”. Mandale House Nursing Home DS0000000185.V248956.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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x x x x x x x Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 Requirement Timescale for action 01/12/05 2 OP21 23 Work must continue to ensure that a fully completed assessment, which includes preferences, likes, dislikes and there should be evidence of service user or their representative’s involvement and also information about the keyworker system. The bathrooms and shower 01/11/05 rooms must have improved lighting and redecoration. The wooded water barrier must be replaced with a more appropriate barrier. A competent, experience and qualified person must be appointed as the manager. 3 OP31 9 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000000185.V248956.R01.S.doc Version 5.0 Page 21 Mandale House Nursing Home 1 2 Standard OP21 OP21 The shower rooms should have shower curtains fitted to increase the privacy and dignity of residents. The signage of the bathrooms, toilets and showers would benefit from being upgraded. Mandale House Nursing Home DS0000000185.V248956.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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