Inspection on 27/01/06 for Mansion House

This inspection was carried out on 27th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mansion House 30/07/07

Mansion House 16/08/06

Mansion House 08/09/05

Mansion House 24/03/05

Mansion House 06/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mansion House Burnham Road Althorne Maldon Essex CM3 6DR Lead Inspector A Thompson Unannounced Inspection 27th January 2006 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 Mansion House DS0000017878.V280800.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. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mansion House Address Burnham Road Althorne Maldon Essex CM3 6DR 01621 742269 01621 742269 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) Mr Francis George Kirk Ms Simone Walmsley Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: Mansion House is a fully detached period property with the original building approximately 600 years old. Its location is on the eastern edge of the village of Althorne which is approximately two miles from the nearest town of Burnham on Crouch. The original building has been considerably extended and is registered to provide accommodation for thirty three elderly people (over the age of 65) in twenty seven single and three shared rooms. Accommodation is provided on two floors. There are three communal lounges and two communal dining rooms on the ground floor available for residents. Access between floors is provided by a passenger shaft lift. Mansion House is set in enclosed grounds, which are accessible to residents. Ample visitor car parking is available to the front of the property. Public transport links include a bus service along the main road directly in front of the home and rail services approximately one mile away in Althorne Village. A local shop is also located in the village. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 1000 hours on Friday 27th January 2006. This was the second inspection of this home in the inspection year 2005/6. The content of this report reflects the inspector’s findings on the day of the inspection, and from taking account of relevant findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Some residents, staff and visitors were spoken with. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All residents spoken to who expressed an opinion confirmed that they were fully satisfied with the care they received and with the accommodation and food offered. Questionnaires were left at the home to ensure that residents not spoken with, and relatives, had the opportunity to make their views on the service known to the Commission. Staff confirmed they received good support from management. They also confirmed that they had been offered training appropriate to their role. What the service does well: What has improved since the last inspection? The home now employs a designated member of staff to undertake general maintenance work. Some internal redecoration had taken place. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 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. Mansion House DS0000017878.V280800.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 Mansion House DS0000017878.V280800.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): 3,5 The home’s assessment format and process was adequate for ensuring that initial perceived needs were identified upon admission. Anyone considering moving into the home may visit to meet residents, staff and facilities, to enable them to assess the suitability of the service. EVIDENCE: The manager of the home or the deputy manager visit prospective residents to carry out a written assessment. The assessment format was unchanged since last inspected and included headings of: background information, next of kin details, medication, manual handling needs, social interests and need, general health needs, mobility, vision, hearing, diet, sexual needs, continence, and includes full manual handling assessment. A separate social history record is also completed and was available for inspection. There was also a separate written assessment of potential pressure area risk. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 9 Prospective new residents are invited to visit Mansion House prior to deciding on a placement, to try to ensure full awareness of facilities available and providing the opportunity to meet with existing residents and staff. Lunch would be offered during these visits. The homes assessment format is completed in addition to any local authority placement assessment. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 10 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): 8,9 The health care needs of residents were generally assured. The home’s medication procedures, practices and staff training were considered to provide adequate guidance for dealing with medicines. EVIDENCE: Residents personal and oral hygiene needs are recorded in the homes assessment format and individual care plans. District nursing services provide tissue viability assessments and guidance/advice on continence issues. District nurses also visit the home to provide nursing services to residents, including those suffering from diabetes. The home also now has access to a continence nurse and an Occupational Therapist will visit to assess residents for any walking aid needs. Equipment for the promotion of tissue viability and prevention or treatment of pressure sores is also provided by district nursing services. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 11 Chiropody, optician tests and dental services are undertaken at the home by visiting practioners. Residents had been referred to St John’s Hospital in Chelmsford for some dental treatment, which could not be performed in the home. Hearing tests are available at a local hospital after referral by the GP. GP practices are provided in Burnham on Crouch and Southminster. The latest good practice guidelines on infection control procedures were in the home and staff had received training on this subject. Nutrition needs were recorded, specialist nutrition advice (community dietician) is accessed through the GP. At the time of this inspection one resident self administered her own medication. This activity had been included in the overall risk assessment for the individual, however the inspector advised the manager to refer to guidance issued by the Royal Pharmaceutical Society, to ensure that the home were complying with latest good practice procedures on this issue. There is a recommendation in this report on this point. The homes policy on the ordering, supply, administering, storage, security and disposal of medicines had been undated since the last inspection. This was in positive response to an advisory visit to the home by a representative from the Local Primary Care Trust, focusing on medication issues in relation to the service and support provided to residents by their GPs, and the supplying pharmacist (which is based at the GP surgery). A copy of the new document was provided to the inspector. Included was clear instructions and guidance to staff on the required procedures. The manager had planned an in-house training session for senior staff on 30/1/06 to ensure they were fully aware of this update. Dispensing/pharmacy services are provided by the local GP practices, medication received into the home is always checked in and unused returns are recorded. Documentary evidence was available for inspection. Initial training is provided by senior staff, to staff who have been identified as possessing the competencies required to be considered for undertaking the role of administering medication in the home. It is understood that only senior carers and management undertake this role. External foundation training on medication issues has been provided to all staff administering or wishing to be considered to take on this responsibility. This was entitled ‘Care of Medicines’, certificates of attendance were seen. Advanced level training had also taken place in 2005. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 12 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): 12,15 Regular opportunities are provided to residents to meet their recreational, social and religious interests and needs. Residents were supported in exercising choice regarding day to day routines in the home. Meals provided would appear to ensure a wholesome, varied and nutritious diet for residents. EVIDENCE: Residents meetings continue to take place, records were available for inspection. Meetings occur approximately four times a year. Items discussed included menus, outings, activities and general day to day issues. These meetings are chaired by a resident, who then liaises with management on issues raised. Residents spoken with confirmed they were fully satisfied with the choices and options made available to them regarding daily routines and leisure interests on offer. They were also complimentary about the care support provided by the staff team. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 13 Activities records are maintained and were available for inspection. In-house activities are decided on each day according to group choice, a member of staff is designated each day to lead activities which had included seated exercise (two staff had been trained to lead this), reminiscence, quizzes, board games, bingo, sewing, manicures. In summer there are outings, residents agree destinations. There is also a summer fete and regular coffee mornings. A hairdresser calls to the home once a week, the mobile library calls monthly, book clubs visit monthly and a clothes shop visits occasionally. Holy Communion services are available in the home on a monthly basis by a visiting local clergywoman. The home supports all residents regarding individual spiritual needs. A volunteer visitor also calls into the home. The main meal of the day is lunch (choice available) with usually a hot or cold choice at tea. Some residents also have a supper snack meal of sandwiches or cake before bedtime. The manager has advised that snacks are also available at night for residents who may be awake. Some residents choose to eat in their rooms the remaining eat in the home’s dining areas. All residents except one (by choice) have breakfast in their rooms. The chef confirmed that cooked breakfasts were available. A member of staff is always on duty in each dining area at mealtimes to offer assistance and support. Nutrition records and menus were inspected and were considered to evidence that a range of choices is available with appropriate nutritional content. Residents spoken with said the food was good. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 14 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 The home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. EVIDENCE: There had been no recorded complaints since the last inspection. The complaints policy met the standard. Included was information to the prospective complainant on whom to complaint too with response timescales. There were also contact details of the registration authority. A copy of the policy is included in the information provided to new residents. Residents spoken with said they knew who to speak to in the home if they any concerns, and that in the past management had responded positively to any queries/issues they had raised. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 15 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): 19,20,21,22,23,24,25,26 Furnishings in the home looked comfortable and areas of the premises seen were well maintained. Private accommodation was comfortable and suited to needs and preferences. The premises appeared safe, were accessible, and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was clean and considered to be hygienic. EVIDENCE: Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 16 Mansion House is a large detached property set in well maintained private grounds. Following inspection of the premises the inspector considered that the home is accessible and well maintained. The needs of individual residents are provided for and accommodation was regarded to be comfortable and homely. Residents have access to the grounds. Several rooms also benefit from the use of small private, individual, walled and paved patio areas. General day to day maintenance is undertaken by the designated maintenance person. There were five communal rooms available for residents, combined space met the recommended standard. Lighting in communal rooms was domestic type and appeared sufficiently bright and positioned to facilitate reading and other activities. Furnishings in communal and private rooms were also considered to be domestic in character and of good quality. There were five bathrooms in Mansion House three of which offered assisted bathing facilities, although one of these was still out of use. All bathrooms had wc’s. There were four separate communal wc’s available in the home and twenty five private bedrooms benefit from fitted ensuite toilets. Sluicing facilities were provided. Rooms inspected were personalised to individual tastes, naturally ventilated with windows and were centrally heated with radiators fitted with thermostatic control valves. Lighting in private rooms was considered to be domestic in character and included table level lamp lighting according to individual needs/risk assessed. Emergency lighting is fitted throughout the home. Hot water supply is regulated at or near to 43 degrees Celsius (not tested). The homes laundry room was fitted with two washing machines both equipped with sluice cycle programmes and washing programmes that met the standard. There were two tumble dryers. The laundry floor finishes were considered impermeable and readily cleanable. Policies and procedures were in place for the control of infection and include safe handling and disposal of clinical waste. Throughout the inspection the premises were considered very clean and free from any offensive odours. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 17 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): 27,28,30 Staffing levels and skills appeared to meet the needs of residents. Staff were provided good training opportunities to equip them with the skills for their role, although some had been unwilling to participate in NVQ awards training. EVIDENCE: The homes staffing rota was inspected and evidence staffing levels are being provided at five carers on morning shifts with four carers on afternoon shifts. Two waking carers work night shifts. The manager and assistant manager’s hours were supernumery. The registered manager has confirmed that staff providing personal care to service users are all over the age of 18 and staff left in charge of the home are all at least 21 years of age. Staffing rotas also evidenced that separate and additional staff are employed for catering, domestic and maintenance duties. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 18 Three staff were undertaking the NVQ level 2 award and two were on the NVQ level 3, although the manager advised that generally established staff were still not supporting/accepting the offer of NVQ training. Full funding support is available. This training is offered to new staff joining the home. National Minimum Standards state that 50 of care staff are trained to NVQ level 2 by 2005. There is an on-going recommendation on this issue in this report. It should be noted that very good short course training opportunities had been offered to all staff in 2005, these are recorded in the last paragraph on this page. The assistant manager had the NVQ level 3 and the manager had NVQ level 4 in Care and the Registered Managers Award. The home’s induction and foundation training process was unchanged. This was based on a workbook format consisting of four modules for induction. These included subjects of principles of care, records, fire & security, manual handling, health & safety, risk assessment, infection control, food hygiene, care of service users, practical care skills, care & use of equipment, needs of service users, activities, settings, specific disabilities. On completion there is a written test paper to complete and a certificate of completion to acceptable competencies is awarded. Staff then proceed on to the foundation section of the package, this covers: value base of care, communication, development as a worker, abuse & neglect, and individual needs. Once competency is confirmed staff are issued with a badge and certificate. Staff training records were in place and copies of certificates of completion were also seen. Training provided in 2005 included: first aid (senior staff are trained to the full ‘First Aid at Work’ level), diabetes, bowels & catheter care, bereavement & loss, COSHH, infection control, manual handling, fire safety, stroke awareness, induction & foundation, continence including fluid monitoring, continence promotion, funeral awareness, bladder & bowel care, POVA (vulnerable adults) & medication. Planned training for 2006 includes NVQ, health & safety and the manager is going to undertake a Dementia ‘train the trainer’ course, which will qualify her to train staff in-house. The manager was also looking into purchasing specialised training packs to extend the overall in-house training available. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 19 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): 31,33,37 The home is run and managed efficiently and effectively. Procedures for gaining the views of residents, relatives and visiting professionals were in place. Records required by regulation were up to date. EVIDENCE: The manager of Mansion House has been in post since 1998. The manager was now qualified to NVQ level 4 in Health & Social Care and had completed the Registered Managers Award. Qualifications previously obtained included NVQ level 3 in management and NVQ level 3 in mental health. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 20 Other qualifications held were HNC in public administration with various other short courses undertaken. The registered manager has confirmed that she was provided with a job description detailing responsibilities and expectations of the role. The home’s quality assurance system was fully implemented in 2005. Questionnaires are provided to residents, relatives and other appropriate persons/agencies (ie district nurses). Sections include questions on staff attitudes, staff knowledge, managers knowledge, food, cleanliness, odour control, atmosphere, entertainment, outings, residents meetings, support provided for healthcare needs, admission process, medication, keyworker system, noise levels, privacy and any other comments. A Q.A. audit and action plan had been compiled from responses received. This consisted of written summaries of identified problem areas, actions taken by whom and the date. Q.A. surveys were in place covering the past two years, these were considered of a comprehensive format and fully met the standard. The new scheduled Q.A. exercise is due in March 2006. Random samples of records required to be kept were inspected. These included regulation 26 reports, fire procedures, regulation 37 notices, accident records, staff rotas, complaints, nutrition records, menus, visitors, photograph of service users & medication. All seen were in order. Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 21 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 3 X Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The registered manager should ensure that the home’s medication procedures for residents who self administer their own medication, have taken account of guidance issued by the Royal Pharmaceutical Society relating to care homes. The registered provider should ensure that at least 50 of care staff are trained to NVQ level 2 or equivalent. 2 OP28 Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Mansion House DS0000017878.V280800.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!