Inspection on 23/01/06 for Mandale House Care Home

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mandale House Nursing Home 136 Acklam Road Thornaby Stockton-on-Tees TS17 7JR Lead Inspector Unannounced Inspection 23rd January 2006 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 Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 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.V266437.R01.S.doc Version 5.1 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 Mrs Grace Eileen Jamison Care Home 57 Category(ies) of Dementia - over 65 years of age (57) registration, with number of places Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 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. 12th September 2005 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.V266437.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection and was completed by one inspector in one inspection day, seven inspection hours in total. A pre inspection document had been completed along with a number of residents and relative surveys. A tour of the home took place along with discussion with residents, staff and the home manager. A number of records were examined, residents file, personal allowance, medication and some maintenance records. Detailed discussion took place with the manager and Operations Manager and whilst a number of requirements were made, these were positively received and steps put into place to address a number of them straight away. There continues to be a commitment to improve standards at Mandale House. It is also acknowledged that the manager is new in post and is in the process of prioritising areas in need of development. It should be noted that only a small number of resident were engaged in discussion about life in Mandale House due to communication and memory problems. What the service does well: Mandale House offers a generally comfortable environment for residents to live in which care needs are well met by a friendly and helpful staff team in a relaxed and flexible way. Relatives said, “It’s excellent here, we are very satisfied, very nice staff team who are friendly and helpful”. Relative surveys stated, “My mother has been in Mandale House for one year and has settled really well. This is largely due to the staff, who are most helpful, obliging to my mother and me. They make her life very comfortable and cared for”, “The standard of care and love given to my mother at Mandale House is excellent. I have no complaints about my mothers welfare at all, highly satisfied”. Residents said, “I am well looked after but am also given time for myself”. They also said, “the staff always knock on the bedroom door, and we all treat each other with respect”. Staff said, “It’s brilliant here, there is a good staff team and really good teamwork we definitely have the skills to meet the needs of the residents”. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 6 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 contacting your local CSCI office. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 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.V266437.R01.S.doc Version 5.1 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): 3 Resident’s needs are adequately assessed prior to admission to the home, which ensure that the home is able to meet resident’s needs. EVIDENCE: Two residents files were examine during the inspection, which contained a completed pre inspection assessment document completed by the home. Also contained within the file was the care manager’s assessment. There was discussion with the manager about the pre assessment process and it was acknowledged that this had been developed since the last inspection and contained much more individual detail. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 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, 9 The assessment and care plans need some additional detail, which sets out fully resident’s health, personal and social care needs and how these needs are to be met. The medication systems are generally in order however the record keeping needs more detail to ensure a more robust procedure. EVIDENCE: Two sets of resident’s files were examined during the inspection with a view to specifically looking at the assessment of need and specific care plans. It was identified that there was still much work to do in this area as in one of the files examined, the full assessment of need had not been completed and there were no specific plans of care in place. In the second file looked at, although there were assessments in place, these were not detailed sufficiently and the care plans were pre written generic care plans and they had not been individualised and did not contain the information required in regard to meeting care needs. The actual daily statement of care were also in need of more information as they predominantly stated, “settled day”. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 10 The medication storage and systems were looked at and it was clear that the senior care worker had a very good understanding of the systems and confirmed that she and all senior staff had received safe handling of medication training. The ordering and receipt of medication was looked at and it was identified that there was no record kept by the home of what they had ordered and there was also some discussion about storage of certain types of medication as well as the medication fridge temperature not being recorded on a daily basis. It was agreed that advice and support would be obtained from the pharmacy advisor at North Tees Primary Care Trust and that the systems would be developed further. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 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): 14 Residents are supported where possible to make decision and have a level of control over their lives. EVIDENCE: During discussion with staff and residents, a flexible approach to live was described with one that encouraged individuality and choice. A staff member said, “the residents are priority here, it is very flexible and relaxing, they have freedom and make own decisions”. During the inspection, a level of flexibility was observed, with residents having a lie in whilst other residents were being consulted about participating in activities. During discussion with a relative and resident they describe a flexible approach to care, they said, “I am well looked after but am also given time for myself”. They also said, “the staff always knock on the bedroom door, and we all treat each other with respect”. It was not possible to fully engage a number of residents in discussion about life within Mandale House due to problems with communication and memory. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were examined during this inspection. EVIDENCE: Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25, 26 Mandale House is generally clean and quite comfortable however further work needs to be undertaken to increase the homeliness, accessibility of bathrooms, shower rooms and toilets and to continue to make a more pleasing comfortable environment. EVIDENCE: A tour of the home took place and in the main was observed to be clean and generally odour free. There was a slight stale odour within the first floor lounge/dining room, which has been an ongoing problem. Handrails were in place on corridor walls and there was a range of equipment such as hoists to meet resident’s needs. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 14 It was identified that there was the need for some environmental improvements this particularly related to bathrooms, shower rooms and toilets. One of the bathrooms was out of use as the fixed bath hoist was not working and some of the showerheads were also in need of attention. Two of the showers were not really accessible to residents with mobility problems and there was the need to improve the flooring in others. These areas were not particularly homely or welcoming and were in need of refurbishment. A number of the ventilation fans were observed to be very duty and needed to be cleaned. It was also identified that there was a problem with the heating systems and one of the lounge areas was cold. It was confirmed through discussion with the manager and Operations manager that there had been a problem and this was currently being attended to. It was also identified that there had been an ongoing problem with the heating system and it was agreed that longer terms solutions to this was needed. A programme of redecoration was also underway and on the day of the inspection, one of dining rooms was in the process of being wallpapered. It was also observed that bedrooms and corridors had been redecorated and general improvements had been made to the home, making the lounge and bedrooms areas more homely and comfortable. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were examined during this inspection. EVIDENCE: Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 16 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, 33, 35, 38 A manager is in post who has the necessary experience and skill to lead Mandale House. A number of systems require further development to ensure the home is run is the best interest of the residents such as quality assurance and management of personal allowances. Accident analysis is not sufficiently detailed to ensure risks are minimised to individual residents. EVIDENCE: A new manager is in post who has the necessary qualifications and experience to manage Mandale House. One relative said, “It’s excellent here, we are very satisfied, very nice staff team who are friendly and helpful”. Staff said, “It’s brilliant here, there is a good staff team and really good teamwork who definitely have the skills to meet the needs of the residents”. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 17 The system for managing residents personal allowances were examined and although there was nothing amiss, it was agreed that these were not robust enough and needed to be reviewed and changed. Quality assurance was discussed and some evidence was seen in the auditing of residents records and medication records. A file containing completed customer satisfaction surveys was looked at however none of these were dated and the summary contained very little detail or information. A random sample of service and maintenance records were examined such as fire equipment, fire drills and training, gas as well as in house records containing evidence of regular servicing of equipment and checking of water temperatures and weekly fire checks. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 18 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 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 3 1 3 X X 2 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 19 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 Work must continue to ensure that a fully completed assessment, which includes preferences, likes, dislikes and there should be evidence of residents or their representative’s involvement. Resident specific care plans must be developed where needs have been identified and must specify what the need is, how it is to be met and by who. (This is outstanding from 01/12/05) The medication systems and recording of medication must be reviewed and altered. The bathrooms and shower rooms must have improved lighting and redecoration. The water barrier in the shower rooms must be replaced with a more appropriate barrier. Broken showerheads must be replace. The bath on the first floor unit Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 20 Timescale for action 01/04/06 2 3 OP9 OP21 13 23 23/01/06 01/04/06 must be repaired or replaced. 4 25 23 The heating system must be repaired or upgraded to ensure that it is working effectively. There must be a programme in place for the regular cleaning of ventilation fans. Quality assurance systems must continue to be developed and introduced and include information about residents and relative views of the service. Regulation 26 reports must be forwarded to CSCI, with immediate effect. The system for managing the resident’s personal allowances must be reviewed and changed to ensure it is more robust. 23/01/06 5 33 24 01/05/06 6 35 17 23/01/06 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 OP19 Good Practice Recommendations The redecoration programme should continue. Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Mandale House Nursing Home DS0000000185.V266437.R01.S.doc Version 5.1 Page 22 - 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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