Inspection on 09/05/06 for Mornington Hall

This inspection was carried out on 9th May 2006.

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 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

Mornington Hall 13/06/08

Mornington Hall 20/09/07

Mornington Hall 18/12/06

Mornington Hall 21/07/05

Mornington Hall 07/04/05

Mornington Hall 01/11/04

Mornington Hall 01/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Mornington Hall 76 Whitta Road Manor Park London E12 5DA Lead Inspector Sarah Greaves Unannounced Inspection 9th May 2006 03:00 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 Mornington Hall DS0000007363.V293392.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. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mornington Hall Address 76 Whitta Road Manor Park London E12 5DA 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) 020 8478 7170 020 8478 6793 www.bupa.com BUPA Care Homes (CFHCare) Limited Ms Patience Ajayi Care Home 120 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60) of places Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 30 at Cornwell House 30 ELDERLY Mentally Ill at Haywood House 30 Elderly Mentally Ill Nursing at Hamfrith House 30 Nursing at Roding House Minimum Staffing Notice Date of last inspection 21st July 2005 Brief Description of the Service: Mornington Hall is a registered care home for older people, owned by BUPA Care Homes Ltd. The home is divided into four separate units; residential care, residential care for people with dementia, nursing care and nursing care for people with dementia. The home is located in Manor Park, within a short walking distance of an overground station and bus routes. There are carparking facilities for visitors within the grounds of the home. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in one afternoon and evening. The inspector spoke to service users, staff, the registered manager and one visitor. This inspection visit focused upon the key standards (as identified in the main body of this report) and checked upon the home’s compliance with the eleven requirements within the previous additional visit inspection report. What the service does well: What has improved since the last inspection? What they could do better: Three requirements have been issued in this report. The home needs to ensure the safe storage of prescribed topical medications, provide a more detailed Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 6 documentation for the clothing needs of service users, and maintain the systems to promote odour free premises. 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. Mornington Hall DS0000007363.V293392.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 Mornington Hall DS0000007363.V293392.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): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The service provided comprehensive written information for prospective service users and their representatives, and ensured that service users were admitted to the home with holistic assessments. EVIDENCE: The inspector looked at the home’s Statement of Purpose and the Service User’s Guide; both of these documents were comprehensively presented and noted to have been written in accordance with the stipulations of the National Minimum Standards and Regulations for Care Homes for Older People. Requirements were issued in the previous inspection report for the Statement of Purpose to provide greater clarity regarding any charges to service users for alternative therapies, and for the home to clearly demonstrate that both the Statement of Purpose and the Service User Guide were periodically reviewed. The inspector found that appropriate information had been added to the Statement of Purpose, which had clearly been reviewed in January 2006. The Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 9 registered manager stated that she had also reviewed the Service User Guide at the same time but this was not documented. The inspector looked at the care plan (inclusive of a Social Services preadmission assessment) for a recently admitted service user on one of the residential units. The care plan contained a full assessment of the service user’s needs. The registered manager informed the inspector of some complex issues related to the care of the service user; the inspector found that the home had sought additional assessments (for example, an assessment by a consultant psycho-geriatrician) to supplement the pre-admission information. Standard 6 was not applicable for assessment, as the home does not provide an intermediate service. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 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 the following standard(s): 7,8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care plans were being developed to present a more detailed account of service users needs; however, this needed further work. Although the systems for the management of medication were generally robust, the home needs to ensure that prescribed topical lotions are safely stored. EVIDENCE: A requirement was issued in the previous inspection report for the home to ensure that service users have accurate care plans to state how their health and welfare needs are to be met. (This requirement was due to be met by 31/05/06). The care plan for a recently admitted service user was clearly written and it appropriately addressed the individual’s specific needs (such as communication, social needs, cognitive functioning and behaviour). The inspector observed a service user wearing an outdoor style formal blazer, whilst sitting in the lounge awaiting an evening meal. Staff stated that the service user insisted upon this choice of clothing; however, the care plan did not document how staff approached this identified need for support. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 11 The registered manager demonstrated that care- planning training had been provided in April 06 and regular auditing of the care plans was being undertaken. Evidence from the care plans and information received by the Commission (Regulation 26 visits and Regulation 37 notifications) indicated that the health needs of individuals were understood and met. The inspector spoke to a relative of a service user who confirmed that the home provided a member of staff to escort the service user to hospital if one of the family was unable to do so. The inspector observed the administration of medication and looked at medication administration records on one of the units; no issues of concern were identified. The inspector found that the prescribed topical treatments for a service user had been left on the service user’s bedside cabinet; the registered manager was advised of the need to ensure that any prescribed creams, lotions etc are safely and securely stored in bedrooms. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 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 the following standard(s): 12 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are offered a broad range of stimulating activities. The food service was described as being good but would benefit from further consultation with service users to determine their wishes. EVIDENCE: A requirement was issued in the previous inspection report for the service to increase the staffing hours for activities and entertainments. The registered manager confirmed that the staffing hours had been suitably increased. The inspector noted that the home offered a wide range of activities such as pub lunches, bingo, visiting musical entertainers and a forthcoming ‘Father’s Day Party’. The home provided sensory equipment in the units for people with dementia; however, the inspector found that the sensory basket on one of the units was very limited in terms of the quantity and range of its contents. The registered manager stated that service users constantly removed these items; strategies to manage this were suggested. The inspector observed the serving of the evening meal on one of the units. It was observed that service users were offered a choice of food and appropriate condiments were provided. Service users informed the inspector that they liked the food, however, some service users identified that they would like a couple Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 13 of choices of soup at their evening meal. The menu displayed on the unit was for a previous day. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are protected through appropriate policies, procedures and staff training. EVIDENCE: The inspector looked at a copy of the home’s complaints procedure, which was comprehensively written. Via discussion with the registered manager, the inspector was informed that there had not been any issues of concern relating to the management of complaints. The home possessed a valid Adult Protection procedure (inclusive of whistleblowing policy) and staff were provided with Adult Protection training. The inspector was satisfied regarding the home’s compliance with Adult Protection issues. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The environment was pleasant, safe and comfortable; however, the home must ensure that protocols to prevent odours are adhered to. EVIDENCE: The home was found to be in a generally well-maintained condition. It was acknowledged by the inspector that a large care home is subject to a continuous programme of redecoration and refurbishment. A requirement was issued in the previous inspection report for the home to ensure that the amplification system for the office telephone is removed from the lounge in Hamfrith Unit (and any other units, if applicable). The inspector observed that the home had satisfactorily met this requirement. The home had re-decorated the skirting boards in the communal corridors, per accordance to a requirement in the previous inspection report. A requirement was also issued for the home to ensure that the suitability of the communal seating is assessed by an occupational therapist or suitably Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 16 qualified person. The registered manager produced a report to demonstrate that this task had been undertaken and the clinical recommendations were being followed. The inspector noted an unpleasant odour in one of the units, which was also detected by the registered manager and a visiting social worker. The inspector observed that the extractor fan had not been switched on; this was remedied during the inspection. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 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 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 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A suitable number and skill mix of staff were allocated to each shift and staff accessed relevant training. EVIDENCE: Via observation on the four units and discussion with the registered manager, the inspector found that there was a safe level of staff allocated to the nursing and residential units. The registered manager stated that a deputy manager had been appointed and would be commencing their post in a few weeks time. The home had not previously employed a deputy manager within recent years; the registered manager stated that this would enable her to spend more time on the units to monitor the quality of care provided. The inspector was shown the training matrix for the home, which demonstrated the on-going provision of staff training (induction for new staff, mandatory training and refresher courses, training specific to the needs of older people and National Vocational Qualifications in Care). No issues of concern were identified with the training information. Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home demonstrated that a more pro-active approach to the monitoring of the standard of care was being undertaken. Appropriate attention was applied to meeting the safety and welfare needs of individuals. EVIDENCE: The registered manager demonstrated that there had been some positive improvements in the management of the service. The inspector was shown evidence of ‘unannounced out of hours monitoring visits’ by the registered manager. A requirement for the managers of each of the four units to be allocated supernumerary management time each week (for providing formal supervision to staff and other managerial duties) had been met. The inspector observed that detailed records were kept of the registered manager’s Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 19 monitoring duties, including daily tours of the units. Minutes were also provided to demonstrate that management guidance was provided through meetings conducted by the manager with senior staff. The home evidenced an active approach towards seeking the views of service users (and their representatives). The measures used to achieve this included annual surveys, letters to relatives/representatives and service users meetings on the general nursing and residential units. Via other regulatory activity, the inspector was aware that external BUPA financial staff had recently audited the home’s financial practices, which was stated to be a periodic practice by the organisation. The registered manager confirmed that some changes to financial policies and procedures were due to be undertaken in order to ensure the rigorousness of the home’s financial systems. The health and safety records and practices viewed by the inspector were noted to be satisfactory, apart from the storage of topical medication (as previously identified in this report). Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A 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 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO 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 The registered manager must ensure that the care plans document whether service users need support with choosing appropriate clothing items to wear each day, and any difficulties that staff may encounter in delivering this care. The registered manager must ensure that topical medication is safely stored in service users bedrooms. The registered manager must ensure that the premises are free from any offensive odours. Timescale for action 31/08/06 2 OP9 13 30/06/06 3 OP26 16(2k) 30/06/06 Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Mornington Hall DS0000007363.V293392.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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