Inspection on 08/09/05 for Mansion House

This inspection was carried out on 8th September 2005.

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 27/01/06

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 Alan Thompson Final Report Unannounced 8th September 2005 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 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 I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 3 SERVICE INFORMATION Name of service Mansion House Address Burnham Road, Althorne, Maldon, Essex CM3 6DR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01621 742269 01621 742269 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 I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 33 persons). Date of last inspection 24th March 2005 Brief Description of the Service: Mansion House is a fully detached period property with the original building constructed approximately 600 years ago. 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 provides 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 spacious 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 half a mile away in Althorne Village. A local shop/post office is also located in the village. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 1100 hours and ended at 1445 hours on Thursday 8th September 2005. This was the first 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 the findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Six residents and three staff 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 were able to express an opinion confirmed that they were fully satisfied with the care they received and with the accommodation and food offered. There were no relatives available to speak with, but questionnaires were left at the home so that they had the opportunity to make their views on the service known to the Commission. Staff confirmed they received good support from the home’s management team, and had been offered NVQ award level 2 training. NVQ level 3 training was being offered to senior staff. What the service does well: What has improved since the last inspection? What they could do better: There were no identified areas for improvement relating to the standards covered at this inspection. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 6 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 I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 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 standard(s) 3 & 5 The home’s assessment format and process was adequate for ensuring that initial perceived needs were identified upon admission of new residents. 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 I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 9 The deputy manager confirmed that 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 I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 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 standard(s) 7 & 10 Care plans in place set out the resident’s daily needs to provide staff with the actions required to meet these. Staff pay attention to ensuring that residents privacy and dignity is respected. EVIDENCE: Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 11 Three care plan files were inspected. These contained admission information, such as next of kin, with a social history and health history. Care plans are compiled using the homes needs assessment format with daily plans of care and instructions to staff under main headings of mobility, continence, sexuality and sexual health, special needs, communication, personal care, mental health, pressure management, nutrition, dental, hearing, sight needs and social preferences. Individual needs are recorded with problem/need, instructions/goal and daily action required. Separate manual handling assessments had also completed. Care plans inspected had been regularly reviewed, although not monthly Individual risk assessments covering identified hazard and risk rating with the perceived consequences and measures to control the risk had been completed. These were held separately from care plan files. Also held separately from care plans were individual fire risk assessments. The deputy manager confirmed that all district nurse, GP visits and other consultations are carried out in the privacy of residents rooms. The three shared rooms in the house are fitted with privacy curtains for this purpose. Sixteen residents had private telephone lines installed in their rooms, for the remaining residents private telephone facilities are provided for by the availability of the office portable telephone. Residents spoken with said they wear their own clothes at all times and confirmed to the inspector that staff refer to them by their preferred term of address. Discussion with residents also confirmed full satisfaction with staff attitudes in providing personal care giving and close personal support. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 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 standard(s) 13 & 14 The home appeared to have maintained good contact with, and encouraged involvement from relatives. Residents were enabled to exercise choice on a day to day and planned basis. EVIDENCE: Visitors are welcome in the home at all reasonable times and meals are provided if requested. Residents are supported by staff in choosing whom they see and do not see. Written information on visiting was included within the homes Statement of Purpose document. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 13 Residents are encouraged/supported in retaining full control of their own financial affairs. Personal allowance monies are held for some residents by the home, for safe keeping. Records had been maintained of balances held and transactions undertaken. Inspection of residents private bedrooms evidenced that some choose to bring personal possessions into the home with them on admission. Records were available for inspection. Independent advocacy services are sought and accessed for residents through the local social services department. Also available locally are fully independent advocacy services. Contact information was displayed around the home and is also included in the service users ‘welcome pack’. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 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 standard(s) 16 & 18 The home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. The home’s adult protection policies, procedures and practices were aimed at ensuring residents welfare. 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. The home had a staff training video package entitled ‘abuse in the care home’. This is shown to all new staff as part of the home’s induction procedures The home also had the latest Essex Social Services guidelines and procedures relating to adult protection and actions expected from staff under this subject. Included were recording and reporting templates and procedures along with definitions of the various recognised types of abuse. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 15 Also in place were the Department of Health’s POVA guidelines (issued in July 2004), and the Essex Vulnerable Adults Committee (EVAPC) reporting/alert forms. Staff were booked for attendance on the EVAPC half day POVA training scheme later in September. The home ‘whistleblowing’ statement/policy continued to meet the standard. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 16 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 standard(s) 19, 20, 21, 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 very clean and considered to be hygienic. EVIDENCE: Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 17 Mansion House is a large detached property set in spacious 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 maintenance person, external contractors are also used when required. 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. Staff advised that they understood this was scheduled for refurbishment into a shower room. 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. The inspection of radiators to ensure that all had been fitted with guards will be checked at the next inspection. 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 I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staffing levels and skills appeared to meet the needs of residents. Staff recruitment procedures aimed at the protection of residents had been followed. EVIDENCE: The homes staffing rota was inspected and evidence staffing levels are being maintained 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. Staff providing personal care are over the age of 18 and staff left in charge of the home are at least 21 years of age. Staffing rotas also evidenced that separate and additional staff are employed for catering and domestic duties The deputy manager advised that a staff NVQ training programme had commenced, this met the recommendation made in the last report. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 19 Staff recruitment procedures were inspected. Two written references, proof of ID, application forms and CRB checks were obtained on new staff. Also on files were training records and contracts of terms & conditions of employment. New staff receive structured induction training. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 38 Financial practices in the home appeared to have been competently managed. Records required by regulation were up to date. The health and safety of residents and staff was generally assured. EVIDENCE: Some residents chose to entrust their personal allowance monies to the home for safe keeping. Records of balances held and of transactions undertaken were presented for inspection and were considered to be appropriately maintained. Remaining residents retained control of their own finances. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 21 Random samples of records required to be kept were inspected. These included care plans, background information and next of kin details, assessments, visitors records, regulation 37 notices, accident records, recruitment records, staff rota, fire drills, fire procedures, complaints, records of personal possessions and monies held for safekeeping. All seen were considered appropriately maintained. The homes premises risk assessment was inspected, this met the standard. The deputy manager confirmed that training is provided to staff in moving and handling training, fire safety, food hygiene, first aid training and basic training in infection control. Individual records seen evidenced this. The deputy manager and some records seen confirmed that the homes electrical installation supply, portable electrical appliances, fixed and portable hoists, fire alarms, fire fighting equipment, staff call bells and shaft passenger lift had all been tested by appropriate contractors. Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x 3 3 Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 23 No Are there any outstanding requirements from the last inspection? 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 Regulation None 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 None Good Practice Recommendations Mansion House I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 24 Commission for Social Care Inspection 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 I56 I05 S17878 Mansion House V Stage 4.doc UI 7.9.05 Version 1.40 Page 25 - 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!