Inspection on 06/09/05 for Mockley Manor

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mockley Manor 24/04/07

Mockley Manor 14/06/06

Mockley Manor 19/04/05

Mockley Manor 05/10/04

Mockley Manor 13/04/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Mockley Manor Forde Hall Lane Ullenhall Warwickshire B95 5PS Lead Inspector Paul Appleyard Announced 6 September 2005 09:30 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. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mockley Manor Address Forde Hall Lane Ullenhall Warwickshire B95 5PS 01564 742185 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) Alpha Health Care Limited Mrs Tracey Maria Parkes Care home with nursing 44 Category(ies) of Old Age (44) registration, with number of places Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19 April 2005 Brief Description of the Service: Mockley Manor is a care home providing both nursing and residential care for 44 residents. It is registered to provide care for elderly residents. They do not provide specialist services, e.g. dementia care. It is privately owned and is part of a growing care home company. It is situated in a small village on the outskirts of Stratford-Upon-Avon and Henley-in-Arden. Access is via a country lane and its location is very rural. Most bedrooms are single, (5 doubles) with views of the surrounding countryside. There are two lounges and two dining rooms available as well as extensive gardens. The buildings are a tasteful combination of old and new build. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours and was announced. This was the second visit of the inspection year. Two inspectors attended, one focusing on care plans and medications and reviewing the residential unit. The lead inspector’s time was spent talking to the manager, examining records, policies and procedures. Both inspectors spent time talking to residents throughout the home and observing staff working practices. Staff were also interviewed in terms of how the home provides care. The care home and the commission are currently investigating a complaint made by a former member of staff regarding staffing and welfare of residents on the residential unit. The outcome is still to be determined but on questioning the staff, residents and observation of care practices, the inspectors have no serious concerns. What the service does well: What has improved since the last inspection? Staff members spoken to report that the manager is approachable and that there is time to give personal care. Staff training in protection of vulnerable adults has been completed and confirmed by staff spoken to. All care staff are being provided with supervision to ensure that they are aware of the aims and objectives of the care home and that they have an opportunity to provide input to the running of the care home and develop themselves professionally. The care home is subject to a major redevelopment in terms of building work and on completion the accommodation will be of a high standard. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 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. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 None of these standards were assessed at this visit; standards 3 and 5 reviewed in the April visit and found to be met. EVIDENCE: Mockley Manor does not provide intermediate care but does provide short-term respite care if occupancy allows. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 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 standard(s) 7 and 9. Care plans reviwed on the residential unit require improving to ensure that the health, personal and social care needs of residents are identified and planned for. Systems for the management and administration of medication are poor in some areas. These shortfalls have the potential to place residents at risk. EVIDENCE: Pre-admission documents used to assess care needs were well documented and risk assessments were in place for key areas of need. Individual care plans are available but need to ensure that all aspects of health, personal and social care needs of residents are identified, reviewed and met. Plans remain brief and lack specific detail in some cases. Daily entries in care records identified changing care needs but these were not reflected in resident care plans. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 10 There was little documented evidence of resident/relative involvement in care reviews. Residents told the inspector that they were happy with the care provided and were well looked after by the staff. Care plans were stored in an open cabinet, and staff confirmed this was normal practice. Daily recordings were also in a communal area, causing a confidentiality concern. Systems for the management and administration of medications were observed. Staff confirmed that they were trained in the safe administration of medicines and that all new staff were trained and supported where necessary by senior staff. There were no controlled drugs currently in use but staff confirmed they knew the procedure and to use a separate register. Medicine administration records were not always completed accurately with a number of omissions noted on the MAR sheets. Staff were observed treating the service users with dignity and respect during the inspection. Care plans on the nursing unit were well organised and had evidence of regular review. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 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 standard(s) 14 The people living in this home have appropriate support to live ordinary and meaningful lives and to participate in and contribute to the community in which they live. EVIDENCE: Several residents spoken to advised that they are able to exercise choice and control in terms of how they conduct their day. This includes seeing visitors and going out with family. None suggested that they were under any pressure to do things to fit in with the staff routine and were able to get up and go to bed as they wished and could spend time either in the privacy of their own room or in communal areas. None of the current residents manage their own financial affairs, the home having clear procedures to manage pocket monies if requested. Many of the rooms were visited, both in the nursing and residential unit and clear evidence of residents having brought in personal items of furniture, photos and ornaments etc, noted. The registered manager is aware of the need for advocates, especially for residents who do not have support from family and accepts the need for such information to be freely available and accessible. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 12 The inspectors did not eat with the residents at this inspection but were advised that the food was good, with choices available. Two choices were available for lunch. During the morning of the inspection several residents and their visitors were observed enjoying a sing-a-long with the home’s activity organiser and accompanying musical entertainer. Residents spoken to told the inspector that they enjoyed this. The manager is still working on developing a residentfocused activity programme taking into account each resident’s wishes. The development of this has been delayed as the staff member appointed has been covering care shifts until recruitment is complete. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 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 standard(s) 0 None of these standards were assessed at this visit; standards 16 and 18 reviewed in the April visit, with standard 16 met and standard 18 needing attention. EVIDENCE: Since the last inspection all staff have received training in the protection of vulnerable adults, this being confirmed by review of records and talking to staff. The care home has a detailed complaints procedure, which is accessible to staff and residents. A number of service users advised they would go to the registered manager. The commission has received one complaint since the last inspection. This was from a staff member regarding staffing levels and welfare of residents and is currently being responded to by the home’s director of care. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 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 standard(s) 21 and 24 There are sufficient toilets and washing facilities to meet residents’ needs. Generally, residents have satisfactory access to specialist equipment to maximise their independence. Residents have their own rooms to suit their needs, which they are able to personalise. EVIDENCE: On the day of the inspection the whole home was found to be clean and tidy. The majority of the service users’ bedrooms were visited during the day. Most have taken the opportunity to bring in personal items to enhance their rooms. Screening is provided in double rooms to ensure privacy for personal care. In terms of infection control, systems are in place to manage laundry and infectious illness. The areas of concern noted in the laundry have been remedied. The home has sufficient bathrooms but two are not used, one being inaccessible to many of the residents and the other not presenting as particularly welcoming. There is an extension being built that will include all en suite rooms and a new bathroom. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 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 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) 29 and 30 The procedures for the recruitment of staff are robust with appropriate preemployment checks carried out thereby protecting service users from unsuitable care staff. An ongoing programme of training is provided to all staff to ensure residents’ needs are met safely. EVIDENCE: The staff files of three recently appointed staff were reviewed and indicated that the registered manager has completed all necessary recruitment checks to ensure the protection of service users. As a matter of good practice the manager keeps a record of all questions asked at interview on file. The company has a training manager and evidence of recent training was noted, including dementia, food hygiene and manual handling. Evidence of new staff receiving a clear induction programme was available. The registered manager reported that the home is planning to have student nurses on placement and views this as positive for all concerned, including the residents. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 16 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) 38 The manager is able to fulfil her responsibilities as manager of the home within an organised management system of policies and procedures, which together with a risk management system protects the interests of residents and is supportive of a safe environment. EVIDENCE: The requirement made at the previous inspection for the implementation of a formal system for staff supervision has been met. Certificates were seen during the inspection for the maintenance and service of most major systems. Records of ongoing servicing were available in terms of hoists and lifts. Staff training in manual handling and fire procedures is continuous. It is apparent that although fire training is provided, not all staff have taken part in recent fire drills. This must be rectified. Clinical waste is now kept secure as required at the last inspection. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 17 A number of staff have had first aid training with first aid boxes on both floors. Environmental risk assessments are in place having been reviewed in February 2005. The accident book is well documented with no patterns identified. The registered provider undertakes a monthly audit and is looking to produce a more user-friendly report. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 18 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 2 15 x COMPLAINTS AND PROTECTION x x 3 x x 3 x x STAFFING Standard No Score 27 x 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 x x x x x x x x x x 2 Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 19 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 38 Regulation 23 Requirement The register person must ensure that all persons working in the care home take part in regular fire drills and are aware of the procedure to be followed in case of fire. The registered manager must keep the residents care plans under review and updated to reflect changing needs. The registered manager must ensure that care records are stored securely. The registered manager must ensure that accurate records must be maintained of medication administered. Timescale for action 31.10.05 2. 7 15 31.1.06 3. 4. 7 9 17 17 31.10.05 31.10.05 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 17 Good Practice Recommendations Advocacy information to be accesible and availble to all interested parties. Mockley Manor E53 S4322 Mockley Manor V240751 060905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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. 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