Inspection on 31/10/05 for Mona Cliffe Residential Care Home

This inspection was carried out on 31st October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mona Cliffe Residential Care Home 19/09/06

Mona Cliffe Residential Care Home 20/02/06

Mona Cliffe Residential Care Home 25/10/04

Mona Cliffe Residential Care Home 19/04/04

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 Mona Cliffe Residential Care Home Blackstone Edge Old Road Littleborough Rochdale Lancashire OL15 0JG Lead Inspector Diane Gaunt Unannounced Inspection 31st October 2005 07.45 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 Mona Cliffe Residential Care Home DS0000017348.V261832.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. Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mona Cliffe Residential Care Home Address Blackstone Edge Old Road Littleborough Rochdale Lancashire OL15 0JG 01706 372566 01706 372566 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) Dr Ravi Kant Sharma Linda Anne Belshaw Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of places 23, OP age 65 years and over Date of last inspection 25th October 2004 Brief Description of the Service: Mona Cliffe is a care home providing personal care and accommodation for 23 older people over the age of 65 years. The home is not registered to provide nursing care. Service users in need of nursing care would need to access the community nursing service. Mona Cliffe is located on the outskirts of Littleborough, with easy access to transport links such as the motorway, train station and bus station. The home is only a short travelling distance from facilities such as shops, restaurants, Hollingworth Lake, and the Pennine Way, although service users would not easily access these facilities on foot. The home is a large stone house, which has been converted and extended to provide residential care. It is set in its own grounds, with ample car parking available to the front of the home. There are 15 single rooms and 4 double rooms. The bedrooms are situated on the ground and first floor. There is a passenger lift. Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by two inspectors over a period of 5 hours. The home had not been told beforehand that the inspectors would visit. The inspectors looked around the building and looked at a number of records. They also spoke with ten residents, one senior carer, one care assistant, the cook, a cleaner, the Registered Manager, the Owner and a District Nurse. Care practice was observed. One requirement listed at the end of the report had not been met since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 6 Care plans must be kept up to date and show that they have been agreed with the resident or their relative. Staff must rest residents’ feet on the footplates on wheelchairs when moving them around the home. The requirements of the Environmental Health Officer’s and Greater Manchester (GM) Fire Officer’s inspections must be met. The manager must have training about how to keep residents safe and the procedures to follow if someone says a resident has been harmed. She should share this training with staff. Staff should not begin work at the home until the manager has got two written references and satisfactory Criminal Record Bureau (CRB) checks applied for by the home. Staff should be reminded of what to do if a resident or relative want to make a complaint. Safety locks should be fitted to bedroom doors and residents offered a key when they move in. 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. Mona Cliffe Residential Care Home DS0000017348.V261832.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 Mona Cliffe Residential Care Home DS0000017348.V261832.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): 3. Assessment of all residents prior to admission ensured their needs would be met at the home. EVIDENCE: Individual records were kept for each resident. Three files were inspected; each contained an assessment undertaken by a care manager prior to admission to the home. With the exception of emergency placements, the manager also met with the prospective resident prior to admission in order to complete her own assessment, evidence of this assessment process was seen on file. The file of one resident, admitted in an emergency, was inspected and it was noted assessment began on admission. The manager was clear that if the home could not meet the needs of a resident admitted in an emergency, the care manager would be requested to find an alternative placement. Mona Cliffe Residential Care Home DS0000017348.V261832.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 and 10. Residents’ health and personal care needs were being well met but this was not always reflected in the documentation, which could result in staff being inconsistent in their approach. Residents were treated with respect by a staff team who understood the need for privacy. EVIDENCE: Three care plans were inspected. Each was based on activities of daily living and had been assessed on a monthly basis. Whilst in the main they detailed the residents’ capacity and assistance required by staff, in some areas they did not accurately record the current situation e.g. two care plans did not record that the residents were unwell and had been cared for in bed for some time; another gave incongruent information regarding diet and weight loss. In both instances, staff were providing appropriate and satisfactory care but the documentation did not reflect the good provision. It was noted that whilst a care plan was in place, a social history and social needs were not recorded with regard to the most recently admitted resident who had lived at the home for 3 weeks. Neither did this care plan record consultation/agreement of the resident or their relative. Whilst the two other plans recorded relative agreement to some areas of the plan, it was not consistent. Residents spoken with did not remember their care plans being discussed with them. Care plans Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 10 did not address spiritual needs, although residents said arrangements were in place for Eucharistic visits for those who wanted them. Risk assessments with regard to nutrition, moving and handling, skin care and other areas of identified risk (e.g. smoking, risk of falls) were held with care plans. When discussed with her, the manager said she would add more information to the falls risk assessments, to include the reason for falling. Care plans recorded GP, Psychiatrist and District Nurse involvement. Appropriate interventions were being taken with regard to residents with or at risk of pressure sores, and suitable equipment was provided. The District Nurse said that timely and appropriate referrals were made and communication from and to the home was clear. Nutritional screening was seen in the care plans and advice to staff to encourage food or fluid intake as appropriate. Food/fluid/turn charts had been in use for two residents who were being cared for in bed but recently discontinued as the manager’s observations indicated staff were consistent in providing this care. The inspector was informed this had been discussed with relatives but there was no evidence of this discussion on the plan. Access to NHS services was upheld and residents said the home called their GP when they needed them. The services of opticians, chiropodist, dentists and audiologist were accessed either at the home or in the community as and when necessary. Three of the residents had sight loss and provision of tapes and talking books was made for them. Staff encouraged residents to take physical exercise in the form of ball games, walking or dancing. Observation on the day of inspection supported this. The continence advisor was appropriately involved and evidence was available that the home asked for reassessment when aids provided were inadequate. If further provision was not made, the home made supplementary provision to ensure they maintained residents dignity in this sensitive area. Staff received training on key care values as part of their induction, this included the importance of upholding residents’ privacy and dignity. Staff interviewed clearly understood the importance of upholding these values and were able to describe their good practice in this area. Observation during the inspection provided further evidence. Lockable space was provided for all residents but door locks operated by individual keys were still not provided. Privacy screens were provided in double rooms and where residents had chosen to let a double room as a single this had been agreed. Residents interviewed considered they were treated with dignity and respect, one of whom said “they treat me very well”, and another who considered they were “well looked after”. Residents looked clean and well cared for, and they expressed their satisfaction with the overall care they received from staff who were “very nice” and “kind”. They felt safe living at Mona Cliffe. Mona Cliffe Residential Care Home DS0000017348.V261832.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): None of these standards were assessed at this inspection. EVIDENCE: Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 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 and 18 Residents were confident that complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse, but staff would benefit from further training in this area to ensure their full understanding of the procedures. EVIDENCE: The home had a complaints procedure. It was included in the Service User Guide, a copy of which was given to each resident on admission, it had also been posted on each bedroom door. A further copy was included in a file for resident/relative information on the notice board in the entrance area. Although staff interviewed were not familiar with the procedure, residents knew there was a copy on the back of their bedroom doors. None of those spoken with had found it necessary to make a complaint. They were given opportunity to raise issues with the manager at bi-annual meetings and saw her on a daily basis should they wish to raise any individual issues. The complaints book was inspected and recorded no complaints since the last inspection. The CSCI had received no complaints during this period either. A procedure for responding to allegations of abuse was available as was the Rochdale Inter-agency Protection of Vulnerable Adults (POVA) procedure. Staff spoken with understood the importance of reporting malpractice but did not have a working knowledge of the procedure. Staff had received some POVA training as part of induction or NVQ level 2, but this was limited. The manager had not attended any specific training in this area. Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 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 With minor exceptions, residents at Mona Cliffe lived in a safe, well-maintained environment. EVIDENCE: A full building inspection was not undertaken on this inspection. Observation showed that the premises were well-maintained and renewal of fabrics and furnishings undertaken as required. Since the last inspection the dining room had been redecorated and new curtains had been provided to both lounges and the dining room. An empty bedroom was being redecorated at the time of the inspection. Non-slip flooring had been provided in the ground floor bathrooms and toilets, and new carpets provided in two bedrooms. A new bath hoist had been provided in the ground floor bathroom and a new call system fitted throughout the building. Required maintenance, and action taken to address identified areas were recorded and monitored by the manager. Environmental Health Officers had visited to undertake a Food Hygiene inspection on 15/03/05 and Greater Manchester Fire Officers inspected on 14/06/05. Not all of their requirements/recommendations had been fully Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 14 actioned. Further comment is made in the Management and Administration section below. Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 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 and 29 A stable staff team with an appropriate skill mix were provided in sufficient numbers to meet the needs of residents. Recruitment and selection practices were in need of improvement with regard to taking Criminal Record Bureau (CRB) checks and references on staff known by the manager in order to safeguard the residents. EVIDENCE: Inspection of rotas showed that sufficient care staff were provided to meet the needs of residents. Feedback from residents was positive with regard to staff who they described as ‘very good’, ‘lovely’, ‘respectful’ and ‘kind’. Observation on the day of inspection provided further evidence of staffs’ skill and kindly manner. Personnel files of three care staff were inspected. One was found to be in order and followed the home’s recruitment policy and procedure. However, two carers had been employed with Criminal Records Bureau (CRB) checks undertaken by previous employers, one of whom had a period of 6 months when she was not working in a care home. Also, a relief manager had been employed for 2 weeks to cover the registered manager’s annual leave without a CRB check or references being taken. In each of these three instances the manager knew the staff personally, and the relief manager and one carer had worked at the home previously. However, it is not acceptable to employ any staff without first taking two written references and CRB or POVA 1st checks. Recent photographs of the staff were not held on all files. Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 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 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): 38 Whilst health and safety of residents and staff was generally promoted and protected, non-compliance with some Environmental Health and GM Fire Officers’ requirements potentially put them at risk. EVIDENCE: An up to date training matrix displayed in the office showed that an ongoing rolling programme of training was provided, which included all mandatory training. Those whose training was due for renewal were undertaking refresher courses. The induction training programme showed that staff were introduced to this training shortly after appointment. Fire precaution checks and drills were undertaken on a regular basis in keeping with GM Fire Officer’s recommendations. Induction included fire training, and staff were required to attend an annual fire lecture. Fire drills were held and the manager planned to include night staff in these. Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 17 Building, fire and COSHH risk assessments were written as required. The fire risk assessments were seen to be detailed. With the exception of the Legionella and annual thermostatic mixer valve service, regular maintenance checks were undertaken in line with legislation. Not all requirements and recommendations of the Food Hygiene Inspection of 15/03/05 and the GM Fire Service inspection of 14/06/05 had been met, although progress had been made towards them. Staff interviewed were aware of their responsibilities with regard to health and safety although they were observed on two occasions using wheelchairs without footplates. They were able to describe their good practice with regard to infection control, and had each been issued with alcohol based hand cleanser. Good practice was observed throughout the inspection with regard to staff hand washing and use of disposable gloves/aprons. Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 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 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 19 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 OP7 Regulation 15 Requirement Care plans must record up to date interventions which have been agreed with residents or their representatives. The manager must undertake training in Protection of Vulnerable Adults (POVA) and share the content of the training with the staff. Water must be stored at 60°C to prevent risk of legionella and supporting documentation held on site. (Previous timescale of 31/12/04 not met) Two written references and Criminal Record Bureau (CRB) or POVA 1st checks must be taken by the home prior to staff starting work. These checks must now be taken up by the home in respect of existing staff. Requirements/recommendations of the Environmental Health Officer’s inspection of 15/03/2005 must be met. Requirements/recommendations of the GM Fire Officers report of 14/06/05 must be met. Wheelchair footplates must be DS0000017348.V261832.R01.S.doc Timescale for action 31/12/05 2 OP18 13 31/03/06 3 OP25 13(3) 30/11/05 4 OP29 19 & Sch 2 30/11/05 5 OP38 13 & 23 30/11/05 6 7 OP38 OP38 23 13 30/11/05 31/10/05 Page 20 Mona Cliffe Residential Care Home Version 5.0 used unless individual signed agreements are in place with regard to their non-use. 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 3 Refer to Standard OP16 OP18 OP24 Good Practice Recommendations Staff should be reminded of the procedure to follow should a resident or relative make a complaint. Additional input relating to Protection of Vulnerable Adults should be included in the staff induction and foundation programme. Safety locks which can be operated by a key should be fitted to bedroom doors. Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Mona Cliffe Residential Care Home DS0000017348.V261832.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!