Inspection on 28/06/05 for Mersey Parks

This inspection was carried out on 28th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mersey Parks 22/09/09

Mersey Parks 30/10/07

Mersey Parks 12/06/06

Mersey Parks 04/12/05

Mersey Parks 28/02/05

Mersey Parks 27/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Mersey Parks 99 Mill Street Liverpool Merseyside L8 5XW Lead Inspector Jeanette Fielding Unannounced 28 June 2005 9:00 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. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mersey Parks Address 99 Mill Street Liverpool L8 5XW 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) 0151 709 4791 BUPA Care Homes Limited CRH with Nursing 150 Category(ies) of OP 60 places registration, with number DE(E) 90 places of places Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) 29 DE/E and 1 named DE aged under 65 years (N - Greenbank House) 2) 30 DE/E (PC - Sefton House) 3) 30 OP and 1 named person aged under 65 years (PC - Princes House) 4) Only 30 DE/E (PC - Stanley House) 5) Only 27 OP and 3 named persons aged under 65 years (N - Springfield House) Date of last inspection 28 February 2005 Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Mersey Parks is a purpose built home, built approximately fourteen years ago. The home comprises five separate buildings, each having a separate management and staff structure. The home is registered to provide care for people aged over 65 years. Springfield House provides general nursing care, Princes House provides personal care, Greenbank House provides nursing care for elderly people with dementia and Sefton and Stanley Houses provide personal care for elderly people with dementia. Each house provides thirty bedrooms together with lounge and dining areas. Mersey Parks is close to local shops and amenities and is located within a short car/bus ride to Liverpool City centre. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over two consecutive days and took a total of 16 hours. During the inspection, service users, relatives and staff were spoken to in order to obtain their views of the home and of the service provided. The records held in respect of service users were inspected to ensure that their care needs were identified and that the appropriate care was given. Staff records were inspected to enable the home to demonstrate that all checks had been made on to ensure that service users were protected and that the staff had been given appropriate training to enable them to provide a high quality level of care. Records in relation to health and safety were inspected to ensure that the service users were accommodated in a safe building and that they were protected. An inspection of the premises took place to ensure that service users were provided with a comfortable and homely environment in which to live. What the service does well: What has improved since the last inspection? Some furniture has been replaced since the last inspection but some additional furniture still requires to be provided. A programme of improvements has been planned. All lounges were tastefully decorated and furnished and it was evident that staff strive to provide a homely environment for the service users. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 7 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. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 8 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 Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 9 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 Detailed pre admission assessments are undertaken on service users to ensure that the home can meet their identified needs. EVIDENCE: A selection of service users files were inspected in each of the five houses within Mersey Parks. The pre-admission assessments identify the specific care needs of each service user and form the basis of the plan of care. Information is gathered from the service user, their family, social worker, GP and any other professional who has been involved in their care provision. The assessments are undertaken by the care manager of the house that they are to be accommodated in or by one of the senior staff as appropriate. Additional information on those service users accommodated for dementia care is gathered from professionals relevant to that specialism. The home does not offer intermediate care. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 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, 8, 9, 10 There is no consistent care planning and reviewing system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: A selection of care files were inspected in each of the five houses. The care files are reviewed by the care managers on a monthly basis or as necessary to ensure that the staff are given full information regarding the care required by the service users. Some files were found not to have been adequately reviewed in line with the changing needs of the service users. Falls risk assessments had not been reviewed for a small number of service users, and whilst staff were able to demonstrate that they were fully aware of the potential risks to service users, and of the action to be taken to reduce those risks, the information was not adequately documented. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 11 Some care files, for those service users who are accommodated for dementia care did not have sufficient information recorded regarding their mental health needs or of how the dementia affected the service user. The standard of care plans and risk assessments varied in the houses with some being detailed and informative and some requiring to be fully reviewed and updated. The daily reports completed by the staff were again varied in the different houses. Some staff made detailed reports giving full information regarding the care they had given to service users during their shift, whilst other staff record only a minimum of information. Records are held to provide evidence of visits to and by GP’s and other health care professionals. This includes the dietician, optician, chiropodist and Tissue Viability Nurse. The medications were inspected in all five houses. In three houses, it was evident that the home’s policy and procedure is followed appropriately. In two houses, staff have failed to ensure that handwritten entries on the Medication Administration Record sheet have been witnessed by another person to ensure accuracy. Some blank spaces were noted on the MAR sheets where staff have failed to provide written evidence that medications have been administered. Two entries on MAR sheets were found to be misspelled where they have been handwritten. This has the potential for the wrong medication to be administered and thereby putting service users at risk. Regular checks by the house managers should be undertaken to ensure that the home’s policy and procedure is followed. All service users are accommodated in single bedrooms. Personal care is given to service users in their bedroom or in the bathroom as appropriate. Service users spoken to confirmed that staff ensure that their privacy and dignity is protected at all times. Service users may meet with their visitors in their bedroom or in one of the communal areas as they wish. Small private rooms are also provided in each house for service users who choose to use these. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 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) 12, 13, 14, 15 Dietary needs of service uses are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Service users spoken to confirmed that the staff strived to provide a flexible lifestyle to meet their individual preferences. They confirmed that they could go to bed and get up at a time of their choosing and that staff respected their preferences. Some houses record the individual preferences of service users, and in those houses where this was not as detailed, staff were able to demonstrate their knowledge of service users preferences. Ministers of religion visit the home on a regular basis to provide services to meet the service users spiritual needs. Few service users maintain links with the local community due to their age, frailty and mental condition. A programme of social activities is provided in the home but this was seen to be more evident in the houses where service users are accommodated for dementia. The home employs designated activities co-ordinators and a programme of activities for each house is displayed. Families and friends are encouraged to visit the home and can meet with service users in one of the communal areas or in the service users own bedroom. Some service users Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 13 have maintained links with the community and all are free to choose whether to attend local churches or social activities. Local social events were seen to be displayed in prominent areas in each house. The menus show that a varied and nutritional diet is available. A cooked breakfast is available on request and special diets can be provided as necessary. A choice is available at all mealtimes and it is evident that staff inform service users during the morning periods of the choice of meals being provided. The meals are prepared in the main kitchen although small kitchens are provided on each house for the preparation of snacks and drinks, and for the serving of meals. The main kitchen is well equipped and clean and all kitchen staff are qualified chefs, cooks or have been given appropriate training. The chef was able to provide evidence of on going training for the staff team. Records are held in the main kitchen of special diets required and of service users individual preferences and dislikes. Meals can be taken in bedrooms, the lounge or in the dining room as the service users prefer. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 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 has a good complaints system and evidenced that service users views are listened to and acted upon. EVIDENCE: The home has a comprehensive complaints policy and procedure. Information on how to make a complaint against the home is detailed in the Statement of Purpose and is also displayed in each of the five houses. Service users spoken to said that they knew who they could complain to and felt confident that their concerns would be acted upon. Records held in the home provide evidence that complaints made in the past have been addressed appropriately and within set timescales. All service users are listed on the electoral register and were given the opportunity to cast their postal votes at the recent local elections. Family members and advocates take responsibility for dealing with legal issues. Service users spoken to during the inspection confirmed that their rights were respected. Relative spoken to also confirmed that they took responsibility for legal matters. The home has a detailed abuse policy and all staff spoken to were able to demonstrate that they were knowledgeable of the procedure to be followed in the event of abuse being suspected. Staff training has been given on abuse and the action to be taken in the event of abuse being suspected. The home has a whistle blowing policy and all staff are made aware of the procedure to be followed and of the confidentiality of this. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 The Owners have a good understanding of the areas in which the home needs to improve. Planning was in place and set out how this improvement was going to be resourced and managed. EVIDENCE: This is a large home, comprising five separate houses, each having thirty single bedrooms, lounges, bathroom and WC’s. General maintenance issues are addressed, usually, as soon as they are reported. The furnishings within Stanley House, Springfield House and Princes House were seen to be good. Some new furniture has been ordered for Sefton House and its delivery is awaited. In Greenbank House, the furnishings in bedrooms was poor at the last inspection, and little has been done to improve this. Furniture has been ordered and its’ delivery is awaited, but in the interim, some service users are not provided with an acceptable standard of furnishings within their bedrooms. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 16 The lounge and dining furniture throughout the home is good, and it is evident that the staff strive to provide a homely environment for the service users. It was noted that some of the toilet tissue holders do not match the type of toilet tissue provided resulting in toilet rolls being place on window ledges, water pipes and cisterns. The manager was not aware that there was a problem with these and will ensure that the appropriate type of tissue is ordered, or the dispensers changed. A new shower unit is planned for Sefton House and this will benefit many of the service users. The bath panel in bathroom 37 was noted to have been damaged and requires replacement. The main problems were identified in Greenbank House. There was a lack of dinner plates and many of the cups were noted to be chipped. Assurances were given that these would be addressed with immediate effect. A new Sensory Room is planned for Greenbank House and work to prepare the room has already commenced. Improvements have been made in bathrooms and WC’s with the provision of blinds which further promotes service users privacy and dignity. Each house has a designated garden area, although some of these have become overgrown, making them unsafe for service users. Service users spoken to were generally indifferent regarding the gardens, with only a few saying that they enjoyed sitting outside in warm weather. All areas of the home were found to be clean and free from offensive odours. The home has an infection control policy and this was seen to be followed by the staff. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, 30 Training is given to all staff to ensure that they are able to meet the individual needs of the service users. EVIDENCE: Each of the houses is staffed independently with a designated care manager to supervise the care provision. The staff rotas provide evidence that each individual house provides staff in sufficient numbers to meet the needs of the service users accommodated. The home provides qualified nurses in those houses that provide nursing care, and qualified care staff in the houses that provide personal care. All senior staff are supported by a team of care staff. The home also provides housekeeping, catering, maintenance and administration staff. All new staff are required to complete an application form prior to interview. Two references are taken together with POVA and CRB checks. A full induction programme is completed prior to new staff being given responsibilities on the houses. A sample of staff files were inspected and found to contain all the necessary documentation required. All new staff are required to complete a comprehensive induction and foundation training programme and staff work with a work based mentor. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 18 Staff training continues to be given to all staff and the records held provide evidence that appropriate training opportunities are available to both qualified and care staff and records of all training undertaken is held on the staff files. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 31, 33, 35, 38 The safety records within this home are well maintained to ensure the protection of service users. EVIDENCE: At the time of the inspection, the manager of the home was due to leave to take up another position. No acting manager had been appointed and the home is looking to recruit a new manager. It is imperative that a new manager is recruited as quickly as possible in view of the high number of management tasks that are necessary within a home of this size. It is evident that the care managers make every effort to ensure that the home is run in the best interests of the service users. The home provides service users with comment cards to enable them to express their views of the home. Comments are welcomed from service users, their relatives and other visitors to the home and are available in the reception area. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 20 The majority of service users have their monies handled by their next of kin or an advocate. The home does not attend to the finances of any of the service users. The home can assist service users to open a bank account within a building society where they can be invoiced charges such as hairdressing or chiropody. Monthly visits are made to the home by a representative of the owners, as required, and a report completed. All staff are made aware that they hold some responsibility for the health and safety matters within the home. All health and safety matters must be reported appropriately and the records show that these issues are addressed as a priority. A central fire log book is held that details all the fire alarm and emergency lighting tests for each of the five houses. These records were found to be well maintained. Tests are also made on the hot water temperatures to ensure that service users are not at risk from scalding. Safety certificates in relation to the fire alarm, emergency lighting, gas, hoists, electricity and portable appliance testing were found to be in order. The gardens require to be addressed to ensure they provide a safe area for service users. Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x 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 Standard No 16 17 18 Score 3 x 3 1 x 3 x 3 x x 3 Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 22 YES 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 7 Regulation 15 Requirement The Registered Person must ensure that care plans are regularly reviewed and updated to contain all information for care staff to provide for the service users. The Registered Person must ensure that all staff follow the homes policy and procedure for the administration of medications. The Registered Person must ensure that all damaged furniture is repaired or replaced. Timescale of 20th June 2005 not met. The Registered Person must ensure that the damaged bath panel in bathroom 37 is replaced. The Registered Person must ensure that all damaged crockery is replaced. The Registered Person must ensure that gardens are made safe for service users. The Registered Person must ensure that a suitably qualified person is recruited to manage the home and an application to register the manager submitted F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Timescale for action 31st August 2005 2. 9 13 12th August 2005 3. 19 23 31st August 2005 4. 19 23 12th August 2005 12th August 2005 12th August 2005 30th September 2005 Page 23 5. 6. 7. 19 19 31 16 23 8 Mersey Parks to CSCI. 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 Good Practice Recommendations Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Liverpool Area Office 3rd Floor 10 Duke Street Liverpool, L1 5AS 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 Mersey Parks F52_F02_s25196_MerseyParks_v228909_280605_Stage 4.doc Version 1.30 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. 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