Inspection on 21/06/06 for Mossley Manor

This inspection was carried out on 21st June 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 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 31/01/06

Mossley Manor 18/10/05

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 Key Unannounced Inspection 09:00 21st June 2006 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.V287958.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. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 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.V287958.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The registered person must ensure that an appropriately qualified person is employed as manager of the care home. That the registration be varied to Old Age not falling within any other category (47 places). 31st January 2006 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 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. Fees at the home are £325 per week. 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.V287958.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day for a total of 8 hours. Care records and associated documents, staff files, management records were examined and discussions were held with staff of all grades, residents and visitors to the home. All residents and relatives spoken to were happy with the service provided. Residents or their representatives completed a total of 10 questionnaires. Ms S Yeadon has been in post since 13th February 2006 following an extended period when the home was without a manager. On the day of this visit the home presented as a happy and relaxed home with staff and residents going about their activities in a calm and unhurried manner. The general satisfaction with the service at Mossley Manor was confirmed by the responses to the questionnaires completed. Responses to questionnaires given to a random selection of relatives / representatives of residents 1 2 Have you received a contract Did you have enough information about the home before you moved in Do you receive the care and support you need Do staff listen and act on what you say Are staff available when you need them Do you receive the medical support you need Are there activities arranged by the home that you can take part in Do you like the meals at the home Do you know who to speak to if you are not happy Do you know how to make a complaint Is the home fresh and clean Yes 8 No 2 3 4 5 6 7 8 9 10 11 Always 8 10 8 10 10 10 10 10 10 Usually 2 2 Sometimes Never What the service does well: Mossley Manor provides a homely, safe and comfortable environment with good sized rooms and residents positively encouraged to personalise their own rooms and a good level of care provided by a well motivated work force. The activities programme continues to develop and provides the opportunity for social interaction with residents both within and outside of the home environment. Residents are positively encouraged to exercise their own choice whenever possible in many aspects of their daily lives. Concerns expressed by Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 6 residents or their representatives are addressed in a timely and effective manner promoting a positive atmosphere throughout the home. 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.V287958.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 Mossley Manor DS0000025193.V287958.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): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have sufficient information to make an informed decision on were they wish to live and may be confident that their needs will be fully assessed prior to accepting a place at the home. EVIDENCE: The Statement of Purpose and Service Users Guide have been updated to reflect the recent changes at the home and includes all of the required elements. The service users guide is available in all rooms for residents and their representatives. It is recommended that a copy of the complaint form be included in the service users guide. A random sample of files was reviewed for statements of Terms and Conditions or contracts. These documents were however kept in the care files. The information contained in these documents is confidential and it is not appropriate for them to be kept in the care files. It is strongly recommended that these and other documents for which the care file is not appropriate should be kept in a separate file and stored securely. Not all files examined Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 9 contained the relevant documents and two of the residents who responded to the questionnaire said that they had not received any. The home manager assesses all prospective residents in respect of their needs. These assessments are carried out with as much input as possible from the resident, their family or representative and any other health care professionals involved in their care. The pre-admission assessments cover all the relevant and appropriate points. The pre-admission assessments are carried out in sufficient detail that the prospective resident may be confident that the home will be able to meet their needs both in terms of equipment and a well-trained staff complement. Mossley Manor encourages prospective residents and their residents to visit the home as often and as for as long as they wish. Residents are offered the opportunity of a four-week trial to enable them to assess the care before making a final decision. Mossley Manor DS0000025193.V287958.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): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning and medication management processes have improved and promote the health, welfare and safety of residents. Residents privacy and dignity are respected at all times EVIDENCE: A random selection of care files was examined on the day of inspection. These included residents of varying ability and needs. All the files examined contained appropriate and relevant risk assessments. Assessed needs and relevant interventions together levels of assistance required were clearly detailed in the care plans. Evidence was seen that changing needs were acted upon and care plans updated accordingly in a timely manner. The new manager is currently evaluating the care plan documentation in order to establish which format is best suited to the home. This has resulted in various forms and documents being used and this is confusing to staff who are required to use the information. The use of a single set of documentation for all residents would be a substantial improvement and give the care planning process the consistency it currently lacks. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 11 Daily report sheets were completed in variable amounts of detail. Some members of staff record a good level of detail whilst others record non-specific comments without giving an indication as to the actual care delivered, the outcome of that care or how the resident has spent their day. The evaluation and review of any care plan must give an indication of the effectiveness or otherwise of the care delivered in accordance with the plan. This evaluation is the justification for the consequent judgement as to whether the care plan is to remain unchanged or modified. There is a need to demonstrate that residents and their representatives are involved in care plan reviews. Evidence was seen that residents are referred to relevant NHS services such as GPs’, District Nurses and appropriate specialist nurses in a timely and effective manner. One resident supported by his family stated that ‘everything is wonderful’, ‘he is exceptionally well looked after’. Medication management is not fully compliant with current regulations and best practice guidelines. The home uses the Nomad system and the new manager is currently looking at moving to the blister pack based Venalink system as a way of improving all aspects of medication management. Photos taken with the residents’ permission were available for identification purposes. Examination of the Medication Administration Record (MAR) sheets showed gaps in the signatures confirming administration. Temperatures for the drug fridges and clinical room were recorded. The use of labels on MAR sheets is not best practice as per the guidelines issued by the Royal Pharmaceutical Society ‘Administration of Medication in Care Homes’. The risk of a label being placed over an existing script is high and this practice should be discontinued. Evidence was seen of one medication having been signed for as given when it was clearly still in the box. There were clear signs that there had been a significant level of over ordering as demonstrated by the high stock levels of some items. The manager was aware of this problem and has taken appropriate steps to address the problem. Mossley Manor DS0000025193.V287958.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 thereby providing independence and individuality for each resident. Meals at Mossley Manor are good offering both choice and variety whilst catering for specific dietary needs or cultural preferences. EVIDENCE: The social and recreational activities have been expanded significantly at Mossley Manor. The appointment of a activities co-ordinator has seen the introduction of a programme of activities that includes various types of puzzles, videos, dancing, exercises, arts and crafts, foot spas, reminiscence, music for all tastes and games. There is also a planned day out each week during the summer months. The activities co-ordinator is in the process of developing an activities profile for each resident in order to establish preferences and development of targeted activities. Members of the care staff take an active part in the activities and supplement the co-ordinators 16 hrs per week. One resident commented when asked ‘there is always something going on’ whilst another stated ‘I really look forward to the trips out’. All the residents receive a monthly newsletter giving details of a large variety of Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 13 things including resident birthdays, trips out, activities which is appreciated by the residents and is regarded as being very informative. There are residents who cannot or do not wish to participate in group activities and it would be beneficial if the hours of the activities co-ordinator were reviewed to increase the time available to do one to one activities. The manager encourages visitors at any reasonable time and residents are able to see their guests privately in their rooms or in a communal area as they wish. Links with the local community are in place and religious ministers of various denominations visit the home on a regular basis and local schools have activities at the home, particularly at times of celebration. On the day of this visit the mid-day meal was observed and was well presented and looked very appealing. Menus were reviewed with the manager who is going to look possible changes. The main meal of the day is served at mid-day and a lighter meal is provided at teatime. Currently the menu shows 2 days with soup and sandwiches and 2 days with a buffet. A reduction in the cold finger food meals would be beneficial and increase the variety of meals provided. Whilst the chef will always prepare to a residents wishes e.g. one resident has a curry made especially for them each week, there is a need to show a choice of meal on the menu to promote and demonstrate choice. Residents had a general view that the food served at Mossley Manor was good with resident comments ranging from ‘the food is excellent’ to ‘very good although it is sometimes a bit dry’. The kitchen and food stores were examined and found to be clean and well organised with all relevant records such as food temperatures up to date. The stores were well stocked and local fresh produce is obtained on a regular basis with minimum reliance on frozen foods. Mossley Manor DS0000025193.V287958.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): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families may be certain that complaints are taken seriously and will be acted upon in a timely and effective manner and those residents are protected from any form of abuse. EVIDENCE: There is an appropriate policy and procedure in place in place for the management of complaints and the procedure is included in the Service Users Guide and displayed in a prominent place at the home. Relevant forms to make a complaint need to be made readily available in the main reception area of the home. There has been one concern expressed directly to the CSCI, which was dealt with in a timely and appropriate manner. There have been no complaints in relation to care at Mossley Manor either directly to the CSCI or to the home. Any concerns expressed verbally by residents or their representatives are dealt with immediately by the manager. It is strongly recommended that a complaints register be established and that all complaints verbal r otherwise are recorded together with details of the actions taken. This would demonstrate the openness and transparency of the home in their approach to dealing with complaints. All residents are registered on the electoral roll and assisted if required to exercise their right to vote at elections. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 15 The home has an appropriate adult protection policy including ‘whistle blowing’. The home has a copy of the Liverpool adult protection manuals and relevant training has been carried out for all staff in this a area. Staff spoken to demonstrated a good awareness of abuse, its’ various forms and recognition the procedures to follow were abuse is suspected or alleged. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 16 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): 19,22,23,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment at Mossley Manor has improved and now provides a homely and comfortable place to live. EVIDENCE: A tour of the home was made accompanied by the manager. The shower room by situated by room 18 is in poor condition and needs refurbishment. The lounge upstairs is in need of redecoration and new floor covering. All rooms were found to be clean and tidy and there were no offensive odours. All rooms showed a good level of personalisation and residents are encouraged and assisted to make their rooms their own. Residents who wish may have a key to their room. A redecoration programme is ongoing and rooms are being redecorated as and when they become empty. There are items of furniture that require replacement throughout the home such as bedside cabinets and the Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 17 manager stated that she had recently completed an inventory of furniture and furnishings which is being prioritised in order that a programme of refurbishment can be started. All sluices and other restricted access rooms were secured promoting the safety of residents. Security at the home is much improved with access being controlled by a remote door opening mechanism rather than the use of the previous digital code system. Maintenance at the home has improved substantially following the appointment of a dedicated maintenance person which is demonstrated by the absence of minor problems such as broken extractor fans, lights not working and loose door handles. One resident when asked about his room commented ‘not bad, I would give it two stars’ and another stated ‘the home is always clean and my room has a good clean every day’ There is a sun deck on the roof of the home, which is popular in the summer months. A comprehensive risk assessment is required in relation to use of this area and residents should only be using it subject to individual risk assessments. The garden to the rear of the home is well maintained and the flagged patio area has been re-laid making it safe for residents. The area has been secured by erection of new fencing and a gate. On the day of this visit the home appeared clean and fresh with no trace of odours. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of care staff employed to meet the assessed needs of the residents but recruitment policies and procedures are not robust and fail to support and protect the residents. EVIDENCE: Examination of the duty rosters showed that there are sufficient numbers of staff in an appropriate skill mix, deployed to meet the assessed needs of the residents. The level of staffing is sufficient to allow for a good level of interaction between staff and residents and for care delivery to be carried out in a calm and unhurried way. There are currently 5 members of care staff with NVQ 2 and a further 3 with NVQ 3. This equates to 50 of the care staff and is commendable given the difficulties the home has had in recent months. There are sufficient staff members with a first aid qualification to have a first aider on duty on every shift. Examination of staff personnel files showed that whilst appropriate references, proof of identity and other documents were present, the procedure in respect of Criminal Record checks and particularly the PovaFirst clearance remains non-compliant. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 19 Documents showed several instances of new staff starting work before PovaFirst clearance was obtained: The procedure for obtaining appropriate clearances was a requirement at the previous inspection and remains a serious non-compliance. The new manager has given an undertaking that no new member of care staff will be allowed to commence employment before the clearance is obtained and then will be required to work under supervision until the full Criminal Records check is received. Failure to comply will result in the commission taking appropriate action to ensure compliance. All staff files examined showed that a form of induction had taken place. This induction was however not in accordance with the Skills for Care Induction and Foundation training. It is recommended that the home consider obtaining a commercially produced product that will promote compliance with this national standard. Staff training at Mossley Manor is ongoing and staff spoken to confirmed this. The new manager is an accredited trainer for Manual Handling and Fire awareness and prevention. Training has included specialist areas such as dementia and infection control in addition to the more general topics such as continence and medication administration. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 20 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): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is able to provide the leadership and guidance required to promote and protect the health, safety and welfare of residents and manage the home in their best interests. EVIDENCE: Appropriately qualified and experienced the manager has been in post since 23rd February 2006 and has made a significant positive impact. Mrs Yeadon holds the registered managers award and has previously held senior management positions in the residential care sector. She is currently applying for registration with the CSCI. The manager has a clear vision and sense of direction and her management style is open and transparent as evidenced in conversations with staff and relatives whilst maintaining a focus on managing the home in the best interests of residents. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 21 The responsible individual makes regular monthly, unannounced visits and submits detailed reports of his findings to the home manager and the CSCI. The manager sees the establishment of an effective quality assurance system as a key part of her role and has started this process by holding regular staff meetings for both day and night staff and meetings for residents and their representatives. The last residents meeting held at the end of March was instrumental in bringing about changes in accordance with residents wishes e.g. increased frequency of religious minister visits, to enhance spiritual care. The home holds monies for two residents. One resident’s monies are forwarded to the next of kin immediately after receipt and the home is looking at having the monies paid directly to the next of kin. The second resident with money held at the home is assisted by care staff to do much of her own shopping and receives lump sums on request. There were no receipts available for the repayment of these lump sums. Additionally, there are no records of amounts received and audit of the balances is not possible. The records relating to management of residents financial interests need to provide more information than at present. It is a requirement that balances are available to be checked at any time by a person authorised to do so. Monies held in a bank account must be in an account separate from the trading and business accounts. Such account(s) must be interest bearing and appropriate amounts of interest allocated to each resident on a regular basis. The manager has commenced formal supervision of staff, which is being is being carried out at the recommended intervals. Both home and individual records are securely stored and in good order, stored securely and used in accordance with the Data Protection Act 1998 thereby promoting and protecting the health, safety and welfare of both residents and staff. Fire alarm and emergency lighting checks are appropriately done and recorded. COSHH assessments had been undertaken and cleaning materials were stored in an appropriate place. On the day of this inspection the home was displaying a valid public liability certificate in a prominent place. All relevant safety certificates for Gas, Electricity, portable appliance tests and hoists were seen and were found to be valid. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 22 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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 3 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 2 3 3 3 Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 23 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 OP2 Regulation 17 Requirement Timescale for action 31/08/06 2 OP7 13 & 15 3 OP9 13(2) 4 OP29 19 The registered person shall ensure that a record is kept of the care homes charges to service users. The registered person must 31/08/06 ensure that all care plans and related documents pertaining to the care of service users are relevant and up to date at all times. The registered person must 31/07/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medications received into the care home in accordance with the Medicines Act 1968 and the Royal Pharmaceutical Society guidelines ‘Administration of medicines in a care home’. The registered person must 31/07/06 ensure that all staff recruited to the care home have satisfactory references and valid CRB/POVA enhanced certificate, before being employed in the care home. (Previous requirement of 28th February not met) Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 24 5 OP30 18(1)(c) The registered person shall having regard to the size of the care home, the statement of purpose and the number and needs of service users - ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform (refer to induction and foundation training) The registered person shall not pay money belonging to any service user into a bank account unless: a) the account is in the name of the service user, or any of the service users, to which the money belongs b) the account is not used by the registered person in connection with the carrying on or management of the care home 31/07/06 6 OP35 20(1)(a)(b) 31/07/06 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 OP1 OP2 OP29 Good Practice Recommendations It is recommended that a copy of the complaint form be included with the service users guide It is strongly recommended that all non-care related documentation be kept separately from the care file ensure confidentiality It is strongly recommended that the registered person obtain a copy of the CSCI report ‘Safe and Sound’ as a tool to assist the improvement required in recruitment procedures. Mossley Manor DS0000025193.V287958.R01.S.doc Version 5.1 Page 25 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.V287958.R01.S.doc Version 5.1 Page 26 - 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!