CARE HOMES FOR OLDER PEOPLE
McAuley Mount Padiham Road Burnley Lancashire BB12 6TG Lead Inspector
Mr Jeff Pearson Unannounced Inspection 19th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 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. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service McAuley Mount Address Padiham Road Burnley Lancashire BB12 6TG 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) 01282 438071 01282 431502 The Institute Of Our Lady Of Mercy Miss Bridget Josephine Carey (Sister Paula) Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st December 2004 Brief Description of the Service: McAuley Mount is a two-storey purpose built care home situated in its own grounds. The home is owned and run by the Roman Catholic Order of the Institute of Our Lady of Mercy. The grounds/gardens are attractive well maintained and accessible to the residents. The home is furnished and decorated to a high standard. The residents’ accommodation includes flats, which consist of a single en-suite bedroom, living room and kitchenette, single en-suite bedrooms and 2 single rooms without en-suite facilities. A passenger lift provides access between the two floors. The philosophy care is underpinned by the Roman Catholic faith, Mass is held on a daily basis in the home’s Chapel. The main aim is of the home is to provide high quality care for older people, both male and female, who feel comfortable and supported in an environment where the Christian values and life style are paramount. Service users’ do not have to follow the Catholic faith and all are free to choose their own lifestyle; everyone is welcome in the Chapel. Staff are available, to provide assistance with personal care and support, in response to individual needs/wishes. Various activities such as a weekly coffee morning, quizzes and bingo are available. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 8½ hours and was carried over one day by one inspector. There were 20 residents accommodated. The files/records of 3 residents were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. During the inspection, the residents, Manager, and staff were spoken with. A tour of the premises was carried out. The food at lunchtime was sampled. What the service does well:
McAuley had a very welcoming, tranquil, supportive and friendly atmosphere. The home was pleasantly decorated the furnishings and fittings were of a very good standard; the residents said they liked the accommodation provided, including their own rooms, shared rooms and the grounds, one resident said “I don’t think you could have a more admirable care home than this” The home was very clean and had no unpleasant odours. The home was being well run and there were enough staff on duty. “We like the comfort and the friendliness of the staff” said one resident. “The night staff are very good at bringing a drink, they emphasize we should call if we want anything,” said another. There were some good care practices in place; staff had an awareness of the residents needs, they treated the people living in McAuley Mount with dignity and respect. The residents spoke positively about the staff saying “It’s nice when staff can have a few words with us, it’s not just us and them” and “If they leave me to answer the bell, they always come back to continue the discussion” People were getting support with medical and health cares, such as seeing the Doctor or attending hospital appointments. The residents spoken with were happy with the activities available including the weekly bingo sessions. Most residents attended Mass in the homes’ Chapel each morning, this was appreciated by one resident who commented, “There’s more time for prayer and to review our lives and get ready for the next life” Visiting arrangements were good; people were being helped to keep in touch with relatives and people in the local community. Staff training and development was ongoing, the managers were supervising staff individually. The catering arrangements were exceptional, all the residents spoken with were expressed their appreciation of the meals provided saying “The food is very good, you can have anything you want” and “We have been trying some new meals, curries, stir fries, last nights chilli was wonderful” Choice menus were available and considerable attention was being given to the meals service. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 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 McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 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): 2, 3 Progress in updating the terms and conditions of residence/contracts, had resulted in clearer safeguards of occupancy for the residents. The admission process ensured the residents’ were properly assessed, their needs and wishes known and planned for prior to moving into the home. EVIDENCE: The copies of contracts of residence looked at as part of case tracking, included the good practice matters as in the specified in standard 2 including room numbers and circumstances when people may be asked to leave, they had been signed by the residents. The resident’s case files seen included assessment information from Social Services as appropriate and staff at the home had carried out pre admission assessments. The assessment details included much relevant information. A copy letter was seen confirming to the resident, the home could meet their needs and that a place was available. Each resident had a care plan in place.
McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 The residents had good individual care plans, but not all needs/wishes had been noted, staff were not being fully instructed to respond to the residents’ individual needs and abilities. The health needs of the residents were being appropriately managed, with the involvement of health care professionals. Support with personal care was provided sensitively in a way which promoted the resident’s privacy and dignity. EVIDENCE: Some residents spoken with had personal care/social/spiritual needs which had not been fully recorded in their care plans. Risk assessments had been completed, the action to be taken in response to the assessment had not been fully included in the care plan. Reviews were being carried out monthly, residents said they had been fully involved with the reviews, and had signed in agreement with their plans. One resident said, “They sit down with us, we sign it each month, it includes a potted history of our lives”
McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 10 Staff said they had been involved with the care planning process they expressed a good awareness of individual residents needs and abilities. Records indicated residents were receiving attention from health care professionals and that general health was being monitored, this was confirmed in discussion with residents and staff. Various health related policies and guidelines were available. Arrangements had been made for staff to receive training in continence management. Residents said they were treated with dignity and respect, this approach and maintaining privacy, was observed within care practices, care plans and records. All the residents have single rooms/flats, which are very much treated as their own private space. The residents said they always get their own mail to open and that they were able to use a telephone in private. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Flexible lifestyles and activities were being encouraged in response to individual and group needs, abilities and wishes. Visiting times were flexible so residents could continue relationships with relatives and friends. Community contact was being maintained to enable the residents to retain links with others. The catering arrangements were exceptional in providing for choice, diet and a pleasurable mealtime experience for the residents. EVIDENCE: Several residents said routines in the home were relaxed and Flexible. Individual care plans included some details of people’s hobbies and interests. A notice on display in the home showed the various activities on offer or planned for. Residents meetings were being held about twice a year. A library service visited the home every other week and the mobile library visited. ‘Coffee Mornings were being held each week and some residents aid they liked playing bingo. The Manager had recently surveyed the residents about the activities on offer. An outing had been arranged November. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 12 The visiting arrangements were detailed in the homes guide. Residents spoken with said visitors were able to call at anytime, and arrangements could easily made be made for privacy. Visitors to home were always offered refreshments. Some residents said they occasionally go out independently or with families and friends. The Manager explained children from the nearby school often visit and that people in the area may attend Mass in the homes Chapel. A computer with Internet access, would be useful in enabling the residents to keep in touch with relatives and friends in other parts of the country and abroad. The residents made very positive comments about the quality, quantity and variety of food available. The four-week menu included choices with in each course. The residents said breakfast was served in their rooms and they could have whatever they wanted, including a cooked breakfast if requested. The cook explained the menu was due to be reviewed and that different meals were being tried out. Diets were being catered for. A four-course meal was provided at lunchtime, each resident’s food was served in individual tureens. The mealtime was seen to be very much an enjoyable social occasion, staff responded attentively and courteously to the residents. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were assessed at this inspection. EVIDENCE: McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 14 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, 21, 26 The standard of the accommodation was very good; providing the residents with an attractive and homely place to live, some matters needed attention to ensure the residents have and appropriate facilities. EVIDENCE: The residents spoken with said they were happy with the accommodation provided at McAuley Mount and expressed an appreciation of the garden and wildlife! “We are getting a bench half way up the drive, so we can have a bit of a rest when we are coming home” said one resident. Records were seen of ongoing maintenance and proposed refurbishment. The home was found to be very clean and free from unpleasant smells. The laundry was suitably located and included appropriate washing equipment and facilities. The domestic staff had had completed infection control training. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 15 The lounges and dining room were attractively furnished and provided pleasant living areas for the residents. The large conservatory had satellite television, a music system and tea and coffee making facilities. New shower facilities had been provided in the apartments, they were very much appreciated by the residents who said they felt much safer with them. Some were still in need of additional handrails and shelving in response to individual needs, the Manager explained this matter was in hand. Assisted bathing equipment was yet to be provided in the first floor bathroom. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 16 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, 29 Staffing arrangements were sufficient in aiming to ensure the resident’s needs are effectively and safely met. Progress had been made in enabling staff to gain recognised qualifications to improve the quality of service for the residents. Staff recruitment practices indicated some improvements needed to be made for the protection of the residents. EVIDENCE: The required numbers of staff were on duty. Staff rotas and records of hours worked, indicated that appropriate staffing levels were being kept with extra staff also being on duty. Residents spoken with were complimentary about the staff team. There were ample catering and cleaning staff employed. An administrator assisted with office duties. Agency staff were being used to cover for staff sickness, holidays and training, the manager explained efforts were made to engage staff that were familiar with the home and residents. The staffing of the home was to be reviewed by outside advisors. The majority of care staff had attained NVQ level 2 in personal care. Four were doing NVC level 2. Three staff had completed NVQ level 3 one was doing this level. The Deputy Manager had completed NVQ level 4 and the registered Managers Award, one senior carer was doing NVQ level 4.
McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 17 Staff records checked were found to have some discrepancies. Employment histories did not include enough detail and there were no records to show gaps in employment had been looked into. No interview notes were available. A reference had not been obtained from one persons’ most recent employer. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 18 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): 32, 33, 36 The management and leadership approach had helped create a supportive, positive environment for the residents and staff. Quality assurance systems were in place to help ensure the home is run in the best interest of the resident. Systems were in place to supervise staff, to offer opportunity for individual development and to monitor progress. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 19 EVIDENCE: The atmosphere in McAuley Mount was welcoming, tranquil, friendly and supportive, relationships between the residents management and staff were good. The residents spoken with expressed an appreciation of the management team and the Institute of Our Lady of Mercy. Staff meetings were being held on a regular basis, records indicated various matters had been raised and discussed. The home had attained the Investors In People Award. Systems were in place to audit the services the provided on an annual basis. A residents satisfaction survey had been carried out, the results of this had been included within the homes guide. Relatives, staff and Community Nurses had also been consulted. Care staff spoken with confirmed they were receiving individual supervisions. A planned programme of supervisions sessions was seen to have been devised. Records of staff supervision sessions seen indicated various matters had been raised and discussed. All staff were receiving an annual appraisal. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 20 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X 3 X X McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 27/01/06 2 OP21 23 3 OP29 17, 19 Care plans must include all identified needs and be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents health and welfare needs. Instructions following specific assessments and risk assessments must be included in care plans. Suitable equipment, which meets 31/03/06 the needs of the residents, must be provided in the first floor bathroom. The recruitment of staff must 30/11/05 include the obtaining and checking of full employment histories, with records kept. References must be obtained from the applicants current employer (Timescale of 28/1/05 not fully met) McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 22 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 OP7 OP29 Good Practice Recommendations The care planning system should respond more effectively to the residents’ emotional and spiritual needs. Notes should be kept of all staff recruitment interviews. McAuley Mount DS0000009511.V252901.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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