Inspection on 18/10/05 for Mossley Manor

This inspection was carried out on 18th 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

Mossley Manor 11/02/10

Mossley Manor 05/05/09

Mossley Manor 28/04/08

Mossley Manor 24/07/07

Mossley Manor 21/06/06

Mossley Manor 31/01/06

Mossley Manor 28/04/04

Mossley Manor 20/04/04

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 Mossley Manor North Mossley Hill Road Mossley Hill Liverpool Merseyside L18 8BN Lead Inspector Les Smith & Julie King Announced Inspection 18/10/05 09:00 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 Mossley Manor DS0000025193.V258374.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. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mossley Manor Address North Mossley Hill Road Mossley Hill Liverpool Merseyside L18 8BN 0151 724 2856 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) Mr Amer Latif Mrs C K Latif Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. A maximum of 47 adults may be accommodated in the category of Older People (OP) of which 47 may be in need of nursing or personal care. 28th April 2004 Date of last inspection Brief Description of the Service: The home was originally built in 1878 and over the years has been modernised and converted to its present state. The home is registered for 47 residents who mainly require personal care. The home is situated in Mossley Hill, a quiet suburb of South Liverpool. Shops, cafes, pubs and public transport facilities are nearby. Care staff are employed to facilitate the care programmes for the residents. The majority of rooms in the home are single occupancy. Ramps and a lift allow access to all parts of the house and gardens. There are communal lounges and dining rooms, which are homely and comfortable. Residents can entertain their visitors in the communal areas or in the privacy of their own room. All residents have their own GPs’ and can access their NHS entitlements. Therapeutic diets can be catered for in the home for those residents who have medical conditions. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory inspection took place over a six-hour period. A full tour of the premises including the kitchen and laundry took place. A selection of records including care plans, staff personnel files, policies and procedures and medication charts were examined. A number of staff and residents were spoken to during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 6 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 Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 7 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): 1,2,3,4,5 The homes Statement of Purpose does not provide enough information for prospective residents so they can be clear about the services the home provides to meet their care needs. EVIDENCE: The homes Statement of Purpose and Service User Guide need to be updated to include all the details required in the National Minimum Standards (NMS) and the Care Homes Regulations 2001. Residents in the home are provided with a statement of terms and conditions and contract when they move into the home. Residents are only admitted to Mossley Manor following a detailed preadmission assessment. All pre-admission assessments are carried out by the homes manager and include direct input from the prospective service users’ family / representative and other health care professionals. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 8 The pre-admission assessments cover all the points listed under standard 3. The assessing person must however ensure that all the relevant areas are completed with adequate information as the assessments seen lacked specific detail and some basic information about prospective residents. Specialist healthcare professionals continue to be involved in the care of residents after they are admitted into Mossley Manor. Residents spoken to during this announced inspection told the inspector that they “I have everything I need”, and “I have no problems”. The manager encourages and promotes visits or trial periods of stay in the home before the resident moves in on a permanent basis. Mossley Manor DS0000025193.V258374.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): 7,8,9,10 There is a consistent care planning process in place that supports the residents by providing staff with the information they need to satisfactorily meet the residents identified needs. Medication management is not fully compliant with current good practice requirements and guidelines. EVIDENCE: A random selection of care plans and related documentation was examined as part of the case tracking process. Care plans included general, handling, mobility, and falls risk assessments. The inclusion of a risk assessment for nutrition will be a recommendation of this report. Care plans are reviewed on a regular basis and the manager is currently introducing a six monthly collaborative review with the residents’ family/representative. Daily reporting is sometimes poor with some entries lacking adequate detail whilst other entries were detailed and corresponded with the care plan and were clear evidence of the care actually delivered to each resident. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 10 On the day of inspection the pressure sores noted in the pre-inspection questionnaire had been resolved following treatment by the district nurse. Records were seen relating to outpatient appointments, doctors visits etc. No residents in the home self medicate and self-medication would only be allowed following a risk assessment. Residents drugs returned to pharmacy are recorded, a date and signature from the pharmacy representative being obtained when returned. On the day of inspection all drugs given were signed for with appropriate reasons given if a drug was not given. A vial of eye drops were found to have no label and not annotated with the date of opening whilst another resident’s medication was over 12 months old. The temperature of the medicine room was in excess of 25o centigrade. This is in excess of the maximum temperature for the safe storage of drugs. The inspector recommended to the manager that the room temperature be monitored and that appropriate steps be taken to maintain the temperature within the safe range. Residents may have a key to their own room if they so wish. During the inspection staff were observed both directly and indirectly engaging with residents. At all times staff were seen to be polite and respectful to residents. Mossley Manor DS0000025193.V258374.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): 12,13,14,15 As far as possible residents have choice and flexibility in how they spend their day in the home, and pursue leisure activities according to their choice and preferences. This allows independence and individuality for each resident. Meals at Mossley Manor are good, offering choice and variety whilst catering for residents dietary needs or cultural preferences EVIDENCE: Daily routines are as flexible as possible, with residents being encouraged to exercise choice and control over their lives. There is a planned limited programme of activities that the residents can choose to attend if they wish. All participation in activities is recorded in the individual care plan. The manager encourages visitors at any reasonable time of day. Links with the local community are in place and religious ministers of various denominations visit the home on a regular basis and the local schools have activities at the home, particularly at times of celebration. A varied and nutritious diet is provided with residents special dietary needs or cultural preferences being catered for. On the day of inspection the inspector Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 12 observed the mid-day meal being served. Meals were well presented and appeared to be wholesome and nutritious. The kitchen and food stores were examined and found to be clean, wellmaintained and relevant records kept. Local fresh produce is obtained on a regular basis with minimal reliance on frozen foods. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 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 the following standard(s): 16,18 The home has a complaints and adult protection policy and procedure in place to help ensure the safety and welfare of residents. EVIDENCE: There have been three complaints made to the home in the last twelve months all of which were responded to in accordance with the homes policy. There has been one complaint to the CSCI regarding the overall management of Mossley Manor. The home has an adult protection policy, including ‘whistle blowing’. The home also has a copy of the Liverpool Adult Protection Manual. POVA (Protection of the Vulnerable Adult) training is planned for all staff. The complaints procedure needs updating to incorporate the CSCI and not NCSC. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 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 the following standard(s): 19,20,21,22,23,24,25,26 The overall structure of the building is of a good standard, with most residents’ rooms being personalized; however maintenance is poor which is not conducive to safe comfortable surroundings and potentially places residents at risk of harm or injury. EVIDENCE: On the day of the inspection the inspector made the following observations: The top floor corridor was malodorous; A very strong odour of urine in room 37, sink unit required repair and call bell not working; Numerous wardrooms were not secured to the wall; Numerous extractor fans in en-suites not working; Flammable materials being kept on top of radiator; Numerous bedside cabinets damaged in need of repair and /or replacement; Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 15 Picture hangers left in walls were pictures had been hung; Wardrobe bracket left in wall after wardrobe had been moved; Radiator cover broken and hanging off; Carpet outside of shower-room frayed and coming away causing trip hazard; Sealant around bath needing replacing; Combustible material (2 mattresses) stacked in fire exit corridor; Two Sofa cushions in lounge badly torn; Resident’s aids (wheelchair and zimmer) stored in sluices: Broken paving stones in rear patio area; Fencing around rear raised area not secure compromising security at rear of home. The inspector was informed that the homes handyman comes on an ad hoc basis. It was a recommendation in previous reports that the hours of the handyman be reviewed given that the home has 47 beds and is on three floors. There is a sun deck on the roof of the home, which is popular in the summer months. There is no risk assessment in place for either the area or the residents that use this facility. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 16 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): 27,28,29,30 Staffing levels are the minimum required levels to meet residents’ needs, however additional staff is brought in for appointments as needed. Recruitment policies and practices are poor and fail to meet the required standard placing residents potentially at risk of harm. EVIDENCE: NVQ training is ongoing for all staff and additional training and development is evident. Four staff have NVQ 2 and the deputy manager has NVQ 3. A qualified first aider is rostered to be on duty every shift. All staff dealing with medications has received relevant training. The homes policy and procedures for recruitment of staff fails to meet the required standard. The staff records examined revealed no valid up to date Criminal Records Bureau (CRB) or POVA enhanced clearance certificates. This is unacceptable and must be addressed as a matter of urgency as discussed at the time of the inspection with the homes manager. One staff file contained a single reference only. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of service users, relatives and staff. The health, safety and welfare of residents and staff is not promoted or safeguarded due to poor recruitment practices, record keeping and policies. EVIDENCE: The manager has been in post for less than a year at Mossley Manor. It was evident that she has a good rapport with residents and staff and holds the registered managers Award NVQ 4. Staff meetings are held regularly and minutes recorded. Morale appears to be good. Staff supervision is in place and is carried out every 6 to 8 weeks. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 18 The registered person must submit a written report monthly on the conduct of the home and forward a copy to the CSCI. This is non-compliance from previous reports and the CSCI are considering taking further action in this respect. Patients’ monies are kept in secure facilities and records of transactions are kept. The employer’s liability certificate was in date and displayed in the main foyer. Gas, electrical and lift/hoist safety certificates nor an up to date fire risk assessment were not available on the day of inspection even though this was an announced inspection and the registered person was on the premises. The small electrical items test – PAT (Portable Appliance Test) was inconclusive as it was not dated or signed. Valid certificates were seen for fire extinguishers, alarm system and emergency lighting. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X 3 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 Standard No Score 16 3 17 X 18 3 2 2 3 2 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 1 Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4,6 Requirement The Registered Person must ensure that the Homes Statement of Purpose is updated and include the services and facilities provided by the home and all the items listed in schedule 1. The Registered Person must ensure that the Homes Service User Guide is updated and include the services and facilities provided by the home for residents. The registered manager must ensure that pre-admission assessments are fully completed in detail including all of the items listed in 3.3 The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medications received into the care home The registered manager must ensure that daily diary sheets are completed in sufficient detail to reflect the care delivered to the resident. DS0000025193.V258374.R01.S.doc Timescale for action 30/11/05 2 OP1 5(1)(af)(2) 6 30/11/05 3 OP3 14 19/10/05 4 OP9 13(2) 30/11/05 5 OP7 14(2) 19/10/05 Mossley Manor Version 5.0 Page 21 6 OP19 23 The registered person must ensure that the premises to be used as the care home are well maintained at all times both internally and externally The registered person must maintain standards of hygiene in the care home, and must keep the care home clean and odour free at all times. The registered person must ensure that all staff recruited to the care home have up to date and valid CRB/POVA enhanced certificate, before being employed in the care home. The registered person must ensure that a monthly written report on the conduct of the home is forwarded to the Liverpool/Wirral office of the C.S.C.I. This is non-compliance from previous reports and the CSCI are considering further action in this respect. The registered person must provide an annual development plan for the home, based upon a systematic cycle of planning/action/review. 31/03/06 7 OP26 16(k) 30/11/05 8 OP29 19 19/10/05 9 OP33 26 30/11/05 10 OP33 24 31/12/05 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 OP7 Good Practice Recommendations It is recommended that residents noted as ‘frail’ or ‘poor diet’ have a risk assessment for nutrition. Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 22 2 3 OP7 OP7 It is recommended that entries on the daily report sheets be expanded to give more detail of the care given. It is strongly recommended that a written consent for the use of side rails be obtained from the resident or representative. It is recommended that the scales used to weigh residents be replaced due to frequent failure rate It is recommended that the registered manager update the complaints procedure to incorporate the CSCI and not the NCSC. It is strongly recommended that the registered person review the hours available for maintenance and that such hours are made available on a regular basis. It is recommended that the registered person employ an activities co-ordinator to develop the range of activities offered and provide more scope for one to one activities. It is strongly recommended that that the registered person employ a typist/administrator to ensure that the registered manager can spend more time in supervising staff and the care given to residents 4 5 OP7 OP16 6 OP19 7 OP12 8 OP27 Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 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 Mossley Manor DS0000025193.V258374.R01.S.doc Version 5.0 Page 24 - 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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