Inspection on 11/07/06 for Mansion House Nursing Home

This inspection was carried out on 11th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Mansion House Nursing Home 10/07/07

Mansion House Nursing Home 08/11/05

Mansion House Nursing Home 10/02/05

Mansion House Nursing Home 14/09/04

Mansion House Nursing Home 26/03/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Mansion House Nursing Home 164 Main Road Drax Selby North Yorkshire YO8 8NJ Lead Inspector Denise Rouse Key Unannounced Inspection 11th July 2006 10:15 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 Nursing Home DS0000027941.V304455.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. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mansion House Nursing Home Address 164 Main Road Drax Selby North Yorkshire YO8 8NJ 01757 618659 F/P 01757 618659 mail@rochehealthcare.com 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) Roche Healthcare Limited *** Post Vacant *** Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability (24) of places Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age range 50 years plus with the exception of one service user aged 46 years 8th November 2005 Date of last inspection Brief Description of the Service: Mansion House is a care home registered to care for up to 29 service users over 65 years of age who require nursing care. The service is provided in a detached house built on two floors; the upper floor is serviced by a vertical lift. There are 23 single rooms and 3 two bedded rooms the majority of which are en-suite. The home is set in well-kept and accessible grounds located in the village of Drax. The home is close to a local post office and shops. Fees range from £432.00 for residential care to £ 575.00 for private nursing, local authority rates were negotiable. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • • • • • A review of the information held on the homes file since the last inspection. Information submitted by the home in the pre inspection questionnaire. An unannounced visit to the home, which lasted seven and a half hours and included a tour of the premises, talking with service users, visitors, relatives, care staff and management. Examination of a variety of records and direct observation of staff working with service users. Information contained in surveys, received from service users, relatives, visitors, and General Practitioners. What the service does well: What has improved since the last inspection? The home had recruited a new manager, and contracted staffing levels had increased, ensuring the continuity of care to service users. The dishwasher, sluice and hoist had all been repaired and were in working order on the day of the site visit, this ensured staff had equipment available for their use. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 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 Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 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 Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 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): Standards 1 3 Quality in this area was adequate. Service users had their needs assessed prior to moving into the care home, however there were some shortfalls relating to the information provided to help service users make an informed choice about the home. The judgment has been made using available evidence including a visit to this service. EVIDENCE: The service user guide was available for each service user in their bedroom. This document was inspected, there were several shortfalls .The relevant qualifications of the provider manager and staff, information relating to the provision of care for service users with physical disabilities, and service users views about the home were not evident. The inspection summary was not from the last inspection undertaken; the information relating to the range of fees charged was not current. This information must be included to ensure that Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 9 prospective service users can make an informed choice about the service based on up to date information. The complaints procedure in the statement of purpose stated complaints could be made to the National Care Standards Commission, not the Commission for Social Care Inspection. This information must be updated so that service users and their representatives have the correct information available to them. However, four service user surveys indicated, three felt they had received enough information, to make a choice about the home, one stated “ I came into the home for emergency respite care and stayed, after researching other homes and decided this was the best”. Two indicated they had not received contracts, one had and one was not sure. All service users must receive a contract to ensure that the service users are aware of their terms and conditions of residency. All four service users who were case tracked had a full assessment of their needs undertaken before being accepted into the home, this ensured that their needs could be met. The pre admission assessment included information relating to social care needs, diet and risk of falls. This ensured that the service users needs would be met. Three out of the four case tracked service users had received a contract. Intermediate care was not undertaken within the home. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 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): Standards 7 8 9 10 Quality in this outcome area was adequate. Service users health care needs were met, however inadequate recording and infrequent reassessment of service users needs, placed some service users at risk of harm. The judgment has been made using evidence including a visit to the service. EVIDENCE: Four service users care profiles were inspected; there were shortfalls in a number of areas. One service user had a care plan for the risk of falls, however this was not completed or signed, this placed the service user at risk from not receiving the relevant care required. Another service user with poor dietary intake had a care plan which stated they needed build-ups, yet it was unclear if this had been followed through, the service users weight had increased slightly, but there were gaps in the recording of the service users documentation in relation to the prevention of pressure sores, which indicated that their condition was not being thoroughly monitored by staff, to ensure the service users needs were being fully met in this area. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 11 Another service user who required a puree diet, and who had swallowing difficulties, had two care plans relating to their weight and swallowing problem. However neither stated food required to be mixed together and pureed finely, this information was known by the kitchen staff. An swallowing assessment by a speech therapist had been requested for this service user. The care plans must be reviewed and re assessed to ensure all relevant information is contained, to ensure the service users needs were being met. Two service users were found to have issues related to restraint by the use of a bucket chair and a seat belt on a wheelchair, which were used “to prevent the service users from falling”. Care plans were not detailed enough; risk assessments were not in place relating to this restraint, which must not occur. This was discussed with the home manager; service users must not be placed at risk by means of restraint. Another service user had developed issues relating to their behaviour, yet there was no care plan in place. The home manager stated that a care plan would be created and a review would be undertaken to ensure that the home were able to meet this service users needs. There was no evidence to confirm that service users were involved in care plan reviews, and it was evident that care plans were not always reviewed monthly, or as the service users needs changed, this must be addressed to ensure service users receive the care they require. It was evident that service users needs were well known, but service users care profiles did not reflect all the care and needs of service users which was being delivered by the staff. Medication systems were inspected, four service users medications were case tracked, balances of medications received were recorded on the medication administration record, apart from one medication for one service user. Controlled medication balances checked were found to be correct. There was evidence of two hand written entries upon a medication administration record; this practice should be avoided to ensure transcription errors do not occur, which may place the service user at risk. Staff must be made aware of the correct method of disposal of medications in line with the provider’s own policy and the Royal Pharmaceutical Society Guidelines. Service users looked well cared for; they spoke highly of the staff who were seen to treat them with dignity and respect. Three service users surveys indicated they received the care and support they required; one stated, “ I have to wait on occasions”. Three surveys indicated that the staff listen and act on what the service user says, one service user stated, “ Some do, some don’t, on the whole staff are good to me”. Two surveys indicated staff were always available when needed, one indicated “ generally staff are aware of my routine requirements for assistance and staff supply them on time”. Privacy was Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 12 ensures whilst personal care was being delivered. Service users were addressed by their preferred name. The manager confirmed that staff were not involved in legal or financial issues for service users. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 13 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): Standards 12 13 14 15 Quality in this outcome area was adequate. Service users receive a wholesome nutritious diet, however there were shortfalls relating to activities being provided at present, which must be addressed. The judgment has been made using evidence including a visit to this service. EVIDENCE: Four service users were case tracked. Service users had their social needs recorded within the pre admission assessment, however this information was not always transferred onto their social activities assessment record. Activities available within the home were listed in the service user guide, however service users were not receiving a weekly programme in a format relevant to their individual needs. This must be provided to ensure service users are fully aware of activities available to them, so they can plan to attend if they so wish. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 14 The activities co-ordinator was not available due to illness; therefore care staff had undertaken to play dominos with the residents the day prior to the site visit. Two service user surveys received indicated that activities were provided by the home that they could “sometimes” take part in. Service users stated, “ There is no one here now to take activities”. Service users were seen watching television in the lounges, or listening to music. They had access to board games, or library books, with normal or large print. One service user was helping to maintain the garden flowers and looked after the homes aquarium. Local outings for residents were provided, once a month using the Roche Health care mini bus. Local clergy also visited the home. The home must provide activities for service users in the absence of the activities co-ordinator to ensure continued social stimulation for the service users. Three surveys from relatives or visitors confirmed service users could receive visitors in the communal lounges or privately in their own bedrooms at any time. The kitchen was inspected, food prepared looked appetizing and well presented. Sherry was available to service users prior to lunch being served. The home had a copy of the Commission for Social Care Nutritional Guidelines available in the kitchen; staff had started to implement this guidance. Food was correctly stored and labelled. Temperature records and cleaning schedules were inspected and found to be correct, this ensured food hygiene and health and safety was being maintained. The chef was aware of service users who required a special diet. A four-week menu was available with a limited choice of foods for teatime and supper that could be pureed; this must be reviewed to ensure service users who require a puree diet receive adequate choice. It was suggested that a higher calorie option should be offered to service users who have weight loss, to ensure their nutritional needs were being met. This was discussed with the chef and home manager. Staff were observed feeding service users at lunch and tea, mealtimes were unhurried and service users who required assistance with their meal were given assistance from the care staff. Service users were observed after lunch, anyone who had required their clothes changing after their meal had been attended to. This ensured that service users dignity was respected. Service users surveys indicated “ there had been great improvements in food in recent months “Another stated“ The food was very good quality”. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 15 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): Standards 16 18 Quality in the outcome area was adequate. Service users could be assured that complaints would be listened to and acted upon, however there were shortfalls relating to abuse training that must be addressed. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There was a complaints policy in operation, however in the service user guide it stated that the manager or deputy should be spoken with, the home does not have a deputy manager, the policy stated that the National Care Standards Commission could be contacted not the Commission for Social Care Inspection, this information must be updated. Information received from four service user surveys indicated that three knew who to speak to if they were not happy. One stated “ I don’t want to make any fuss” Three visitors surveys indicated that they were aware of the homes complaints procedure, one indicated that they had made a complaint in the past, and that they were satisfied with the overall care provided. There had been four complaints made since the last inspection, the Commission had investigated two for Social Care Inspection. An action plan relating to a complaint investigated by the Commission was discussed fully with the home manager in relation to the required outcomes for service users; Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 16 the correct outcomes were seen, being delivered on the day of the site visit. Documentation relating to the complaints was inspected, this included the actions taken to investigate the complaints and the recorded outcome for service users, and all complaints were dealt with within 28 days. Four staff files were inspected; one member of staff had received health and safety training. A new member of staff had not started their induction training, which included abuse training; this places service users at risk, and must be addressed. One member of staff had no written references on file; therefore service users may not be protected from staff that might not be suitable to be employed in the care sector. These shortfalls must be addressed. The home operates a whistle blowing procedure, one staff file did not contain evidence that a Criminal Records Bureau check had been undertaken, this must be undertaken for all staff to ensure they are suitable to work with vulnerable adults. Mansion House Nursing Home DS0000027941.V304455.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 26 Quality in this outcome area was adequate. Service users live within a building that was adequately maintained, however there were some shortfalls, which may compromise service users safety. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The service provided a homely environment for service users, with a rolling programme of maintenance being undertaken by the handyman, who had redecorated a lounge and dining area. The home had spacious airy corridors downstairs and a wide variety of communal areas and two dining rooms, which were all decorated to well. This ensured the areas were pleasant for service users, visitors and staff. However there were a number of shortfalls with the environment, which may place service users and staff at risk. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 18 Four service users surveys indicated that they all felt the home was fresh and clean. There were gloves, aprons and hand wash facilities available throughout the building, which helped to ensure adequate infection control. Patio doors leading to the gardens were open in both lounges, one dining area, as well as in a number of service users bedrooms. The home manager must ensure that security is maintained; to prevent the possible unauthorized access to service users and staffs possessions by an intruder. A risk assessment must be undertaken to address this issue. One bathroom on the ground floor was poorly decorated and smelt musty; there was no hoist available to assist staff bathing service users in this bathroom. A second bathroom had been fitted with a hydraulic bath which provided excellent bathing facilities, however the floor covering in this bathroom had not been extended under the new bath, this would not allow the floor to be properly cleaned and this must be replaced. The garden and lawns looked well kept, however the wooden garden furniture required sanding down and re-varnishing, the garden fountain required maintenance work to be undertaken to clean it out and to ensure that it did not pose a drowning risk for service users and visitors to the home. A risk assessment must also be undertaken to ensure that service users and visitors were not placed at unnecessary risk when utilizing the garden around the fountain. Flagstone paths down the side and back of the home must be made level and safe for service users and staff to walk on, to prevent the risk of falls. The double garage used as storage for all three Roche Healthcare homes must be kept tidy and the doors closed. This area was an eyesore and detracted from the pleasant exterior of the home. The radiator cover in room 16 was broken; this must be replaced to maintain the service users health and safety. Room 22 had a stain on the bathroom floor, and it was unclear if the previous requirement to replace the toilet and bathroom flooring had been undertaken. The home manager must ensure that this has been carried out. The service users en–suite bathroom fans were covered in dust; this must be removed to prevent this from becoming a fire hazard. The sluice was not locked and was easily accessed, there were chemicals seen to be stored within this area which must be locked within a cupboard to prevent them from being a possible risk to service users. The hairdresser’s salon also had products easily accessible which could have been hazardous to the health of service users and staff. A lockable cupboard must be provided. The laundry was dusty and the floor required moping, generally it was untidy. A service user was exiting the laundry as it was about to be inspected. There Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 19 was a build up of fluff and dust behind the washers and dryers, also blue plastic aprons and a discarded cushion, which must be removed from behind the washers and dryer to ensure that this does not become a fire hazard. The door was open and the lock had been removed, leaving a hole in the door. The door would not be affective as a fire door; therefore staff and service users were being placed at risk. The lock must be replaced and access to the laundry must be restricted to staff only. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 20 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): Standards 27 28 29 30 The judgement in this outcome area was adequate. Service users were looked after by adequate numbers of staff, however there were shortfalls relating to staff records and training, this may place service users at risk. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Contracted staffing hours for qualified staff had increased by 84 hours per week, since the last inspection, excluding the home managers hours. Staff stated that they were relieved that the home had a manager in place; they stated they would speak up if they had any issues, but at the moment they had no concerns. The manager stated that she was aware that staffing had been an issue, but that this was mainly due to the lack of contracted staff which had improved recently, and staff sickness at short notice. She stated that all avenues would be taken to address inadequate staffing levels when staff phoned in sick, if no cover could be found then she would undertake the shift herself as the service users needs would always come first. Surveys received from two local GPs indicated that they had had concerns, there was not always a senior member of staff on duty to talk with, and also Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 21 that communication had been difficult. This was discussed with the manager, who stated she would liaise with all the GPS to ensure that any issues were resolved immediately. A service user survey indicated, “ We have nice staff here” another survey indicated, “ There was not always sufficient numbers of staff on duty”. And “ The staff all make visitors very welcome, usually with a cup of tea after a long journey, sometimes staff seem to be over worked, with only the very minimum number on duty”. The surveys indicated that they were, however satisfied overall with the care provided. Separate domestic staff were employed by the home so that care staff did not have to undertake cleaning. The home does not have 50 of their care staff that hold a National Qualification in Care, at level two or three. The home must strive to achieve this to ensure care staff have the relevant underpinning knowledge and expertise to administer care to service users. Staff recruitment has improved recently and this provides stability of the workforce and helps to achieve continuity of care for service users. Four staff files were case tracked this included two new recruits to the home. All folders contained an application form; one did not contain any written references, and a second only one reference. One file did not have evidence that a Criminal Records Bureau check had been completed. Two files contained no evidence of Induction, and two files indicated there had been no supervision, one file had three supervisions recorded, and one new starter had not received any induction. The home must ensure all staff receive training and supervision, all outstanding areas must be addressed, to ensure that service users are not placed at risk. The home manager provided names of staff that had just undertaken fire training. One of the four case tracked staff had received the appointed first aid training, however it was not clear if the home had sufficient covered in relation to this, this must be addressed. It was suggested that a training matrix be commenced to help identify outstanding staff training needs. This would ensure that care would be delivered by staff that had received training, which would promote service users health and well being. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 22 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): Standards 31 33 35 38 Quality in this outcome area is adequate. Service users financial interests were safeguarded, however the lack of a permanent management has affected the service provided for service users, however the shortfalls in the service were being addressed. The judgement has been made using available evidence including a visit to the service. EVIDENCE: The newly appointed manager had good knowledge and experience within the nursing care sector and will be applying to become registered with the Commission for Social Care Inspection. The home will benefit from consistent management and staff will benefit from constant support. Staff stated, “ We are pleased a new manager has arrived”. A survey indicated “ There was a drop in the general standard of the home, I believe caused by Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 23 lack of a manager. There are now signs of improvement”. The acting manager was seen on the day of the site visit regularly walking round the home and observing the care that was being provided, conversing with service users, visitors and staff, this ensured that the quality of the service being delivered was being constantly monitored and the manager could be accessed easily by everyone within the home. An annual development plan was in place, which had yet to be discussed with the home manager. Discussions undertaken indicated that all departments within the home would be audited to ensure that the standard of service being delivered was monitored and any shortfalls would be addressed. This process would be undertaken by the manager to help her to understand the level of service currently being provided. Some relative questionnaires had been sent out from the home, in the past, this would be repeated, the results of the questionnaires were not known by the manager, who stated a thorough quality assurance system would be implemented over the next few months. Personal allowance accounts inspected for the four case tracked service users were found to be correct, all receipts were present for transactions, which had been made. This ensures that service users were protected from financial abuse. The home had general risk assessments in place, but required some specific ones to be created in relation to the fountain in the garden. General maintenance was undertaken and there was evidence that lifts and hoists were serviced and maintained. Safety certificates were available for gas and electrical appliances and fire systems had been tested and maintained. However here were some environmental issues which needed to be addressed relating to health and safety within the home and gardens. The manager should send a copy of the report undertaken when senior management have attended the home, to the Commission for Social Care Inspection for review. Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 456 Requirement The statement of purpose and service user guide must contain all relevant up to date information as described, to ensure service users; relatives and visitors can make an informed choice about the service. It must include up to date information relating to fees. All service users care plans must be completed in enough detail, and signed by staff. All care plans and risk assessments must be reviewed at least monthly or as service users needs change. To reflect service users current needs. Previous time scale of 06/01/06 not met. 3 OP8 12 (1) (a) & 13 (8) Service users must not be restrained by the use of bucket chairs, and seat belts upon wheelchairs. These issues must be reviewed in relation to each service user. DS0000027941.V304455.R01.S.doc Timescale for action 20/08/06 2 OP7 15 (1) (2) (b) 20/08/06 20/08/06 Mansion House Nursing Home Version 5.2 Page 26 4 OP12 16 (n) 5 OP15 16 (i) The registered person must ensure that service users social needs are recorded within a care plan. Activities must be provided which are suitable for service users needs including those who are physically disabled. A programme of activities must be circulated to all service users in a format, which is suitable for them. The registered person must ensure that the teatime and supper menu can be pureed so that service users requiring a puree diet have an adequate choice of food. The registered provider must provide induction training and training in abuse awareness to all new and existing staff. 31/08/06 20/08/06 6 OP18 13 (6) 30/09/06 7 OP26 8 OP29 23 (2) Ensure access to the laundry is (d)&13 (c) restricted to staff only. Replace the lock to the laundry door. Clean and tidy the laundry, remove all items and dust from behind the washers and dryer. 19 All staff must have two satisfactory written references on file. All pre employment checks must be undertaken and documented for each member of staff. 18 (1) (i) First aid appointed persons training must be undertaken to ensure the home has adequate cover on all shifts. Fire training must be completed in line with the North Yorkshire Fire service guidance. The registered provider must ensure that staff receive formal supervision at least 6 times a year. DS0000027941.V304455.R01.S.doc 31/07/06 31/08/06 9 OP30 31/08/06 9 OP36 18 (1) (i) 31/08/06 Mansion House Nursing Home Version 5.2 Page 27 9 OP38 23 (2) (b) (d) Redecorate the ground floor 31/08/06 bathroom, which has an unpleasant smell. Re assess the bathing facilities in this bathroom to ensure they can be utilized for service users. Replace the floor covering in the downstairs bathroom with the new hydraulic bath. 10 OP38 13 (4) (a) 11 OP38 13 (4) (a) 12 OP38 16 2 c j 23 2 k The registered provider must undertake a risk assessment in relation to maintaining adequate security for the home when patio doors are open. The registered provider must undertake a risk assessment relating to the garden fountain. This must be cleaned out and measures put in place to ensure that it does not pose a drowning threat to staff, service users or visitors. The following maintenance issues must be addressed: Assess the toilet and flooring in room 22.Repair or replace as necessary. Replace the radiator cover in room 16. Remove the dust from all service users en-suite bathroom fans. Sand and varnish all wooden garden furniture. Ensure all flagstones to the side and rear of the building, are flat and even to walk upon. Ensure the sluice is locked. Provide a lockable cupboard in the sluice and hairdressing salon for storage of chemicals, which may be hazardous to health. 31/07/06 31/07/06 01/09/06 Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 28 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 2 Refer to Standard OP15 OP28 Good Practice Recommendations The registered provider should consider providing higher calorie choices on the menu for service users who are prone to loosing weight. The registered provider should ensure that staff are encouraged and supported to achieve their National Vocational Qualification in Care at Level two or three. The home should strive to have 50 of staff who hold this qualification. The registered provider should send a copy of the report produced following a regulation 26 visit, to the Commission of Social Care Inspection. The manager should continue to develop the quality assurance systems within the home. 3 OP31 4 OP33 Mansion House Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Nursing Home DS0000027941.V304455.R01.S.doc Version 5.2 Page 30 - 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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