CARE HOMES FOR OLDER PEOPLE
McAuley Mount Padiham Road Burnley Lancashire BB12 6TG Lead Inspector
Mr Jeff Pearson Unannounced Inspection 22nd February 2006 09:45 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.V281542.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 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.V281542.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th October 2005 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 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 lifestyle 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.V281542.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 8 hours over 1 day and was carried out by 1 inspector. There were 19 people accommodated in the home. During the inspection the residents, registered manager, deputy manager and staff were spoken with. The files of 3 service users were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of service users. Various records and policies were looked at, including the records of the two most recently employed staff. A tour of the home was carried out. The manager completed a pre-inspection questionnaire. What the service does well:
This home aims to provide good quality care and support for current and future residents. The management team were cooperative in their approach to the inspection process. The home was being well run and there were plenty of staff. 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. The home was very clean and had no unpleasant odours. One resident commented “I’m very happy here its grand, the care is terrific and the food is lovely” People were getting support with medical and health cares, such as seeing the Doctor or attending hospital appointments, they were being encouraged as far as possible, to make their own decisions and choices about things which affected them. Staff training and development was ongoing. The residents appreciated the care and attention provided by the staff and relationships between everyone in the home were good. I’m very satisfied, the staff are very good, I like them all, I’m just glad that I’m here everyone is exceptionally nice” said one resident “Very understanding staff with a sense of humour” said another. The home was well maintained and health and safety matters were being appropriately managed, for the benefit of the residents, staff and visitors. McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 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.V281542.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were fully assessed at this inspection; please refer to the previous inspection report dated 19th October 2005. EVIDENCE: McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 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): 6, 8, 9 The residents had good care plans which included details of their individual needs and up to date instructions for staff. The health needs of the residents were being appropriately managed, with the involvement of health care professionals. Medication management was satisfactory, but additional policies and procedures were needed for the benefit of residents and staff. EVIDENCE: Residents spoken with were aware of their individual care plans and said they had seen and agreed with them. The care plans looked at included much relevant information about the residents’ needs and wishes, including personal care needs and daily living activities. Spiritual and social care needs had been included. Records showed reviews were being carried out each month. Various health related policies and guidelines were available. Records indicated residents were receiving attention from health care professionals and that McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 10 general health was being monitored, this was confirmed in discussion with residents and staff. Medication and records looked as part of cases tracking; were in found to be in order. Storage was good. All senior staff with responsibilities for medication had attended accredited training, or were due to receive training. Policies an procedures were in place covering matters such as administration of medication, record keeping, self medicating, ordering and prescriptions. . There was no policy or individual protocols for ‘when necessary’ medication, or a policy on covert administration of medication. McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 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): 14 Residents were being given the opportunity to make choices and decisions, to enable them to have as much control over their lives as possible. EVIDENCE: The residents had been encouraged to bring their own personal possessions and furniture with them. Individual care plans showed people were being consulted about their lives. Residents meetings were being held about twice a year. Residents were seen to be supported and enabled, to make their own choices and decisions, for example at lunchtime various meals were offered. Financial arrangements and procedures for accessing written information were outlined in the homes guide. Most residents were looking after their financial matters. Residents spoken with felt they still had a degree of control over their lives, one said “we can do whatever we want”. McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Systems and procedures were in place to provide for the effective management of complaints. The vulnerable adults policies, procedures and staff training in protection issues ensured that people living in the home were properly protected. EVIDENCE: There had not been any complaints made at the home. The residents spoken with were keen to emphasise they had no complaints, but they were aware of the complaints procedure. The procedure for making complaints was in the homes guide and on display in the entrance hallway. The procedure was seen to include all the necessary details and contact information, clarification needed to be sought on who will respond to complaints now that an area manager had been recruited. The management of complaints was discussed with manager and deputy. Good policies and procedures were in place for dealing with complaints, including investigations. The homes protection/abuse policies included information based upon the ‘No secrets ’ guidance, Procedures for reporting allegations, suspicions or incidents of abuse were seen. Guidance and procedures were available on dealing with aggressive behaviour. A policy on physical intervention was seen. Some staff had covered protection and abuse matters as part of NVQ (National Vocational Qualifications) training. An in-house training session on protection and abuse had been arranged for early March. The staff and the whistle blowing policy was seen to include appropriate referral information.
McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 13 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 appropriate facilities. EVIDENCE: The home was found to be very clean and was 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. The residents spoken with said they were happy with the accommodation provided at McAuley Mount and expressed an appreciation of the garden and grounds. A bench had been provided half way up the drive, so the residents could have a rest when walking home. Handrails had been provided next to outside paths. Records were seen of ongoing maintenance and proposed refurbishment.
McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 14 The lounges and dining room were attractively furnished and provided pleasant living areas for the residents. One lounge had been re-decorated and a new carpet fitted. The large conservatory had satellite television, a music system and tea and coffee making facilities. The homes Chapel provided for quiet reflection as well as the daily morning services. Additional handrails had been fitted in the residents’ showers and arrangements had been made for shelving to be provided. Assisted bathing equipment was yet to be provided in the first floor bathroom, the manager explained that this matter was in hand. McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 15 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, 29, 30 Staffing arrangements were sufficient in aiming to ensure the resident’s needs are effectively and safely met. An improvement in staff recruitment practices, showed appropriate attention was being given to protecting the service users. Induction training and the programme of ongoing staff development, promoted effective support and care for the residents. EVIDENCE: Residents spoken with were complimentary about the staff team. There were ample catering and cleaning staff employed. An administrator assisted with office duties. 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. The use of agency staff had ceased as a member of staff had been employed to provide cover for holidays and sickness. Staff records checked were found to have all the required information and clearance checks had been carried out. Interview notes had not been kept. Staff had been provided with contracts of employment. Records were seen of completed and ongoing induction training, new, unqualified staff were being supported to start NVQ training as a matter of
McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 16 course. Training records showed staff development was ongoing. Copy certificates were available on staff files. Discussions with staff confirmed various training courses were on offer and staff meetings were being held. McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 38 The manager of McAuley Mount had the ability, experience and qualifications to effectively manage the service for the benefit of the residents and staff. The management and leadership approach had helped create a supportive, positive environment for the residents and staff. Health and safety was being promoted for the benefit of the residents, staff and visitors. 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. Sister Bridget, registered
McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 18 manager, had been at the home for 16 years. She had a nursing qualification, NVQ level 4 in management and the Registered Managers Award. The manager job description was dated 1999 it was therefore suggested this be reviewed and updated. The acting deputy was also nurse qualified, her experience, skills and support complimented the management team at McAuley Mount. A new area manager had been recruited by the Institute. The home was found to be free from any obvious hazards to health and safety. Health and Safety policy statements were available. Health and safety risk assessments had been completed. The pre inspection questionnaire showed equipment had been serviced and that installations and maintenance checks were ongoing. Fire drills were being carried out, fire equipment was being checked and tested. All senior staff had completed First Aid training. Training in safe working practices, such as moving and handling and infection control was ongoing, or being arranged. McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 X X X X X 3 McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? 1 (within timescale) 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 OP21 Regulation 23 Timescale for action Suitable equipment, which meets 31/03/06 the needs of the residents, must be provided in the first floor bathroom. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Policies and procedures should be defined and introduced in relation to when required (PRN) and variable dose medication. Criteria for the administration of when required and variable dose medication; should be clearly defined and recorded for each service user prescribed such items. Policies and procedures should be defined and introduced in relation to covert administration of medication. 2. OP9 McAuley Mount DS0000009511.V281542.R01.S.doc Version 5.1 Page 21 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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