Inspection on 23/05/07 for Mandale House Care Home

This inspection was carried out on 23rd May 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 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 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 09/07/2008.

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 23rd May 2007 10:30 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.V340288.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.V340288.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 F/P 01642 674007 T L Care Ltd Mrs Julie Hickey 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.V340288.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. 9th May 2006 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 £353 - £355 per week for older people depending upon the local authority and £353 - £371 of older people with dementia. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was completed across three-inspection day, twelve inspection hours in total. As a key inspection all of the Key National Minimum Standards for Older People were looked at. This was to see how well the home met the required standards with the main focus on health, safety and well being for the people who live there. Residents were involved in conversations about their lives within Mandale House as were relatives, staff and the manager. A number of records were looked at, this included, residents care files, staff files and training records, medication records as well as maintenance records. The Annual Quality Assurance Assessment (AQAA) was completed and returned by the manager and this forms part of the evidence contained within this inspection report. There was some discussion about the AQAA and the need to increase the level of detail and the benefits of it as an internal quality self-assessment. What the service does well: Mandale House provides a reasonably pleasant and comfortable place for people to live. Residents’ rooms are pleasantly furnished, decorated and personalised with individual items of the residents own choosing. Residents spoken to believed they are well cared for by a friendly and helpful staff team. Resident spoke positively about their life and care within Mandale House. They said, “I can make my own decisions, I definitely feel safe here and feel that I have made the right choice and am settling in”. A relatives survey stated of what the home does well, “Provides excellent care with exceptional staff who are always pleasant while carrying out an enormously difficult job”. Residents also said, “I find the girls very helpful, they try to make it as pleasant as possible. They never say they are too busy although they sometimes are”. Through discussion with residents and staff it is clear that choice and autonomy is encouraged. Staff said, “It is a flexible life for the residents, we encourage choice and decision making, the needs of the residents always come first”, “It is a nice place to be, the residents get what they want, when they want it”. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 6 The staff are very well trained with 99 of staff being qualified to NVQ Level two or above, this is excellent. What has improved since the last inspection? What they could do better: Of the National Minimum Standards looked at during this inspection, a number of requirements and recommendations have been identified. The Manager must continue to address those issues requiring action, which are detailed at the back of this report. Work should continue on the care records ensuring that all of them are brought up to the standard of those looked at during the inspection and that appropriate risk assessments and care plans are in place. Staffing levels on the ground floor units were not adequate to fully meet the needs of the residents. Immediate action was taken to address this. A number of areas within the home needs to be improved to make the environment better for the residents. This includes attention to two shower rooms that are out of use and have been since the last inspection. Consideration should also be given to the use of three other shower rooms that have never really been used due to difficulty of access by residents. A number of ensuite sink units must be replaced, as they are severely water damaged. In the upstairs unit, there was still an slight underlying unpleasant odour. The extractor fan in one of the upstairs toilet was not working. The external area at Mandale House is very difficult to access due to being built on an incline and the resident areas are above the garden access. An accessible patio area has been developed; this is now quite uneven with an incline in the middle of it and some loose paving, which could cause difficulty for some residents. A number of health and safety matters need to be addressed including increasing the frequency of checks on the fire alarm system and monitoring of the hot water to which residents have access. The policies and procedures continue to be in need of review and update, which the directors have been dealing with for some time. This is essential to ensure that people have the required information and guidance to follow, again to ensure safety, protection and well being to the residents. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 7 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.V340288.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.V340288.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs assessed prior to moving into Mandale House. EVIDENCE: All residents have care files in place, four of which were looked at during this inspection, two from each unit, two of which were new admissions to the home. The four files looked at contained pre admission assessment along with the care management assessment. The manager confirmed that prior to resident’s being admitted into Mandale House, key staff would complete the home’s assessment to ensure that individual’s needs could be met by the home. It was also confirmed that reviews take place a short while after admission to ensure satisfaction with the service. The Annual Quality Assurance Assessment stated, “New residents are admitted following full assessment being carried out by the Home Manager or Unit Manager. An up to date Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 10 assessment and a copy of the care plan is obtained from their Social Worker or Community Psychiatric Nurse”. One resident said, “It was a difficult decision to move here, my family had a look and made the decision as it is within close proximity to my home and I am hoping that this will help with visitors”. Mandale House Care Home DS0000000185.V340288.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are happy with the care provided and care records are in place with detailed assessment of need, although some additional development is needed to ensure all residents have specific plans of care. The system for managing medication is reasonably satisfactory, however some slight review is needed to promote protection. EVIDENCE: Resident’s assessments of need and care plans were looked at in the four care files selected. Two of the most recently admitted residents had their records looked at. The manager had completed these assessments. They generally contained a good level of detail and the personal care assessments were very detailed, individual and clearly demonstrated the residents care needs. In one of the records, whilst the assessment of need was in place, no care plans had been developed, which were needed, as the resident was a diet controlled diabetic and also suffered from Parkinson’s disease. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 12 In one of the other files looked at there were some areas of care needs that had been identified, however supporting risk assessment and care plans had not been developed. These related to the potential of the resident leaving the home and potential verbal abuse. The moving and handling assessment were also not fully completed, in all of the records looked at as they did not specify the height and weight, which is needed to ensure that the outcome of the assessment is accurate. The care records had improved since the last inspection and now contained more personal information and details of care needs. They were also becoming much more person-centred and in one of the files it contained information such as; “Would really like to do, Would really like to go - I would like to go to South Shields to see a show”. They did not show that there was a process for consultation with residents and/or their relatives and that agreement had been obtained. Relative were spoken to and they confirmed that they were going to have some discussion about their loved ones care needs to ensure that these were being carried out in the way they would have wanted. Staff also confirmed that they were keyworkers for a number of residents and they were actively involved with completing residents care records. Details for GP’s, District Nurses, Optician and other health care professionals was detailed within all of the files looked at. During the inspection, a GP was observed to visit and there was also an emergency situation, which the staff managed extremely efficiently, with confidence and sensitivity. One relative survey stated, “They always inform us if they have to call out the Doctor, if her medication is changed and on one occasion she was admitted to hospital and they informed us instantly. I had trouble finding staff at the hospital to update me on her condition. I told a staff member at the home when I popped in to get some nightclothes, they rang the hospital immediately and got information for me”. Resident spoke positively about their life and care within Mandale House. They said, “I can make my own decisions, I definitely feel safe here and feel that I have made the right choice and am settling in”. Staff said, “It is a flexible life for the residents, we encourage choice and decision making, the needs of the residents always come first”, “It is a nice place to be, the residents get what they want, when they want it”. The medication systems was looked at and there was a good system in place for the ordering of monthly medication and also good arrangements for medication such as antibiotics that were needed outside of the normal ordering arrangements. Appropriate arrangements are in place for the administration of medication and returns of unused medication. The storage for the medication is only adequate. There are two medication rooms, both are very small with Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 13 little ventilation and no hand-washing facilities or facilities to wash the medication pots. The temperatures of these rooms is nearly always recorded upstairs, however there were some gaps. It was confirmed through discussion that the staff who administer medication are appropriately trained and the manager said that ongoing competency assessment are carried out. The medication was being administered in the ground floor unit and this was being appropriately completed. It was identified that there is the need to increase the frequency of audit of controlled drugs and also to obtain up to date British National Formularies. The policy and procedures continue to be in need of review and updating to ensure that staff have the appropriate guidance to follow to ensure the safe handling of medication within the home. Mandale House Care Home DS0000000185.V340288.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 good. This judgement has been made using available evidence including a visit to this service. Activities are in the main satisfactory for residents ensuring social, religious and recreational needs are reasonably provided for, these could be linked to a more detailed social and lifestyle assessment. Residents where possible are able to control aspects of their lives, their independence and make choices. Residents are provided with nutritious meals with variety. EVIDENCE: The AQAA detailed that daily life and social activity information is gathered and documented for each resident. There was some detail contained within the files looked at but it was unclear how this information was then translated into individual and group activities within the home. An activities person continues to be employed within the home and a range of activities was described by staff including, going out depending upon the weather, card games, music, karaoke, coffee morning and bingo. There were mixed views about the recreational and social activities with some people believing that more could be provided. One staff member said, “Life for the residents can be a little boring, we need to do more in the way of activities Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 15 and have the activities person’s equipment available when they are on holiday”. A relative also said, “There could be more activities and stimulation, the activity person works on both floors but often people go into sleepy mode as there is not enough interaction”. This was evident on the ground floor during one of the inspection days and thought to be linked to staffing levels, which have since been increased. The manager confirmed that there was an activities programme, which is a four week programme, which includes; craft afternoons, sing-a-long, ladies makeovers, and a range of board or games such as carpet bowls and skittles. The activities organiser is employed for fifteen hours per week on set days. A number of visitor were observed during the inspection and it was also confirmed that resident were able to go out of the home and that they were welcomed by a friendly and pleasant staff team. The menu was made available and it was a rolling menu and primarily consisted of traditional British food. It was observed during the inspection that residents are given a choice of meals. One resident said, “The food is really lovely”. One of the relatives said they had had some discussion about the food, as it did not always suit their loved ones preferences and there was not enough fish included in the menu. They said that some improvement had now been made to this. The inspector joined the residents on the ground floor unit for lunch, which was well presented, there was evidence of choice and residents generally seemed to be enjoying their meals, although some had to wait a while for their to be served. It was noted that two of the residents would have preferred smaller portions and were put off slightly by the large dinner plates. The manager and one of the supervisors did confirm that their meals would usually have been served on smaller plates. The more specialist diets, such as soft and pureed would benefit from improvement to the presentation as discussed with the manager during the inspection. Mandale House Care Home DS0000000185.V340288.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. This judgement has been made using available evidence including a visit to this service. Residents and relatives are aware that if they had any concerns or complaints, these will be dealt with quickly and effectively and robust procedures are in place to protect residents from abuse although further staff training is needed. EVIDENCE: The AQAA detailed that there had been three complaints since the last inspection, which had been dealt with appropriately and that a thorough system is in place to manage and investigate complaints. Residents who were spoken to said if they had any concerns they would raise them with the manager or other members of staff. Members of staff said they were aware of the complaints procedure and were confident in following this procedure should the need arise. A relative said, “I can easily raise issues and concerns, these are dealt with”. There have been a number of adult protection issues raised, all of which have been appropriately reported and investigated and the appropriate management action taken. Staff confirmed they had received training on the topic of No Secrets and would know what to do if needed. The training matrix did not detail that all staff had received this training. Further training is planned for staff and manager believes this topic should be covered on a regular basis, thus keeping everyone updated. Mandale House Care Home DS0000000185.V340288.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): 19, 20, 21, 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are provided with a reasonable environment in which to live, it could be made better with some environmental improvements and more attention to safety checks. EVIDENCE: The environment was clean, reasonably well maintained and decorated. The home is divided into two specific units; one that provides care for older people, the other that provides care for older people with dementia. The ground floor unit provided a large lounge area with a slightly separated quiet area away from the television and a pleasant dining room. All of the rooms on the ground floor were single rooms with ensuite facilities. A number of sink units were in need of replacement within the ensuite areas, as these were severely water damaged and there could be the potential of cross-infection. One of the ground floor shower rooms was also out of use and Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 18 had been for some time due to water seeping through from the shower room above. It was also noticed that there were tiles missing from the shower room next to the visitor toilets and these needed to be replaced. In the upstairs unit, there was still an slight underlying unpleasant odour. One of the shower rooms was out of use, which was the one above the ground floor one previously described. Three of the shower rooms could only be used if resident are extremely mobile as there were steps in place and little room to move or to be supported by care staff should this be needed. The extractor fan in one of the upstairs toilet was not working and again a number of ensuite sink units needed to be replaced. Comments received during the inspection in relation to the upstairs unit, was that there was a lack of more private, quiet space for the residents. There is a large lounge area combined with the dining area as well as a quieter area. Whilst steps had been taken to partition and divide these areas, it is non-the less still one large room, which provides the full communal space of the residents. If possible, it is recommended that thought be given to trying to achieve some separate space that could be used for a number of functions. The external area at Mandale House is very difficult to access due to being built on an incline and the resident areas are above the garden access. An accessible patio area has been developed; this is now quite uneven with an incline in the middle of it and some loose paving, which could cause difficulty for some residents. There are another two patio’s areas available for resident use with the support of staff, these means leaving the home through the main entrance to access them, as such, not really freely available for resident use. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by a well-trained and qualified staff team although not necessarily by the appropriate numbers of staff. EVIDENCE: Staffing levels were discussed with a relative, staff and the manager during the inspection and direct observations also took place. Staffing was considered to be sufficient to meet the needs of the residents on the first floor unit. This was not the same within the ground floor unit, where two staff were having to meet the needs of twenty residents. The manager did confirm that they were in the process of recruiting new staff, however this was taking some time and they were trying to support the staff in the meantime. Staff spoken to were clearly under pressure and felt that they were only just meeting the residents needs and they had no time to actually spend with the residents due to workload and dependency needs. One member of staff said, “I don’t feel we are fully meeting the residents needs, I have been under a lot of pressure, it’s never been like this before, everything is rushed”. The inspector spent some considerable time in the ground floor lounge, throughout this time, there was no staff presence and no one observing or interacting with the residents. Immediate action was taken to address this and additional staff were available less than twenty-four hours later. The duty rota reflected this and staff confirmed that the levels had been increased. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 20 A number of staff files were looked at during the inspection and contained the information needed to show that good recruitment procedures are in place and followed. This information included, evidence of identity, Criminal Record Bureau checks as well as two references. The Manager stated that no new staff commences employment without full clearance from the Criminal Record Bureau, which include Protection of Vulnerable Adults check The AQAA detailed that 99 of care staff are qualified to National Vocational Training Level two or above in care, which is excellent. Induction was discussed, and the manager confirmed that any new staff who did not have a National Vocational Qualification in care would undertake the Skills for Care Induction. The training programme was looked at as well as a training matrix, which detailed all of the mandatory training such as fire, moving and handling and first aid. It was recommended that a matrix be developed to show that client’s specific training that takes place. Staff training records were looked at and they contained copies of certificates and confirmation of qualifications. One staff member said, “I complete all of the mandatory training and have achieved NVQ Level 2 and 3”. Another staff member also confirmed this and said that they had also completed Dementia Care training, which was very good. Staff were very clear about their job roles and believed that one of the strengths of the home was the staff team. They said, “W have a good core staff team and we all help each other, we update each other and everyone knows what they are doing”. A relatives survey stated of what the home does well, “Provides excellent care with exceptional staff who are always pleasant while carrying out an enormously difficult job”. Residents also said, “I find the girls very helpful, they try to make it as pleasant as possible. They never say they are too busy although they sometimes are”. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst an appropriately qualified person manages the home, a number of areas have been identified as in need of improvement. This is to ensure that the residents benefit from an environment where there are good safety checks and up to date policies and procedure. EVIDENCE: The manager has the appropriate qualifications, skill and experience to manage Mandale House. A relatives survey stated, “My mum was in two other homes for respite care and they cannot compare to this one”. Residents said, “I like living here, there are nice people and the food is very good”, “It’s going better that expected, it’s early days as yet but seems fine so far”. Whilst there are quality assurance systems in place, these have not been completed on a regular basis and there is the need to increase these again. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 22 This included in-house environmental audits, care plan audits and mediation audits. A quality assurance survey had commenced and the manager said she was in the process of analysing the responses and would then be preparing report for residents, staff and relatives. The management of resident’s personal allowances was well managed with good supporting records. The AQAA detailed that the maintenance and servicing of equipment such as fire systems and emergency call systems are up to date. A random sample of in house maintenance records were looked and these needed some further action. There is the need to ensure that safety check take place as the required regular intervals, such as weekly fire equipment checks. It was noted that the water temperature were not being properly recorded and were not being checked at the required frequency. A sample of policies and procedures were looked at and they continue to be in need of review and updating. This has been ongoing for some time and the directors did appoint an organisation some time ago to complete this work. This remains outstanding and the present policies and procedure do not give the guidance needed to fully ensure that the home is operated in the best interest of the residents within safe frameworks. Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 23 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 3 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 2 2 2 2 X X X X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 24 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 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. New BNF’s are need for both units and there must be more regular audit of the Controlled Drugs. Training on the protection of vulnerable adults must continue and must be rolled out to all staff and this must be recorded to show that all staff have received this training and are able to promote protection of the residents. There must be systems in place to ensure safety to resident at Mandale House including regular checking of water temperatures and fire checks as well as environmental audits and repairs as detailed in other requirements. Timescale for action 30/09/07 2. OP18 13 30/09/07 3. OP19 13/23 30/08/07 Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 25 4. OP20 13 5. OP21 23 The patio area leading from the 30/09/07 ground floor lounge must be improved as there are loose paving slabs and gaps and it is even and could present potential tripping risks to residents. The number and mix of 01/11/07 bathrooms and shower rooms must be reviewed to ensure that there is an adequate mix to meet the resident’s needs. The out of order shower rooms must be repaired.(This is outstanding from the inspection of 9/5/07) A number of ensuite sink units must be replaces as they are water damaged, not pleasant and could potentially be a cause of bacterial growth and infection. 6. OP27 18 7. OP38 13 8. OP38 13 Staffing levels must be reviewed on the ground floor area and there must be sufficient staff on duty to fully meet the needs of the residents. The policies and procedures must be reviewed/updated and must provide staff, residents and relatives with the information they need to ensure safety, wellbeing and protection. Water temperatures and fire checks must take place on a weekly basis to ensure health and safety for the residents living at the home. 04/07/07 30/09/07 04/07/07 Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 26 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 The assessment and care records should continue to be developed and a range of a specific care plans should be in place, demonstrating how individual residents needs are being met. The recreation/social activities programme should be developed in accordance with detailed social and lifestyle assessments to ensure that residents have social outlets related to their lifestyle needs. The quality assurance systems should 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. All handwritten entries on MAR sheets should be signed, dated, and countersigned to reduce the risks of mistakes. 2. OP12 3. OP33 4. OP9 Mandale House Care Home DS0000000185.V340288.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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.V340288.R01.S.doc Version 5.2 Page 28 - 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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