Inspection on 24/07/07 for Mossley Manor

This inspection was carried out on 24th July 2007.

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 21/06/06

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 Mrs Claire Lee Unannounced Inspection 09:15a 24 and 25th July 2007 th 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.V340049.R01.S.doc Version 5.2 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.V340049.R01.S.doc Version 5.2 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 Samantha Yeadon Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum 47 service users to include:*Up to 47 service users in the category of OP (Old age not falling within any other category). To accommodate one named service user under the age of 65 years Date of last inspection 15th November 2006 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 forty seven residents who require personal care and support. The home is situated in Mossley Hill, a quiet suburb of South Liverpool. Shops, cafes, pubs and public transport facilities are nearby. Residents are provided with single rooms; the two double rooms are currently being used for single accommodation. The home has equipment and aids to assist residents who require help with their mobility and 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 these areas or the privacy of their own rooms. A call bell system with an alarm facility operates throughout the home to enable residents to call for assistance. The fee rate for accommodation is £333.00 a week. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection over two days for a duration of approximately eighteen hours. A complaint investigation also took place at this time. Forty four residents were accommodated at this time. A partial tour of the premises took place and a number of the home’s care, staff and health and safety records were viewed. Discussion took place with twelve residents; three care staff, the home’s activity coordinator, cook and registered manager. During the inspection five residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Interviews also took place with three relatives. All the key standards were inspected and also previous requirements and recommendations from the last inspection in November 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents, relatives and health care professionals prior to the inspection. A number of comments included in the report are taken from the site visit and also the survey forms. Surveys were received from four relatives. None were received from residents or health care professionals. A Commission pharmacist conducted a pharmacy inspection on 31st July 2007 and the findings are incorporated in the main report under Standard 9 of the National Minimum Standards. An annual quality assurance assessment (AQAA) was completed by the manager prior to the site visit and some of the information from the assessment is contained within the report. The AQAA provides details of the service and the current staff and resident group. What the service does well: Mossley Manor had a pleasant welcoming atmosphere and residents appeared happy and settled. Visitors were seen popping it a various times of the day and residents could meet with them in the lounges or in the privacy of their own rooms. Residents spoken with were pleased with the standard of care and support given to them. Residents are positively encouraged to exercise their own choice whenever possible in many aspects of their daily lives. This was Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 6 observed and discussed in relation to meals, social arrangement and time of getting up in the morning and retiring at night. Several residents said they preferred to have a bath later on in the day and that staff accommodated this wish. Comments regarding the care included: “Good care” “Lovely staff” “The girls are around to help me all the time” “I can decide when I want to get up and have breakfast” Staff were observed to be respectful in their approach when talking with residents and also assisting with various aspects of personal care. A resident reported, “The girls are always polite and treat me in the right way”. Although the menu was not displayed residents stated that they received a good choice of different meals and that the food was tasty and well presented. One resident reported, “The main meal is at lunch time and it is always very good”. What has improved since the last inspection? The needs of the residents are assessed prior to their admission to Mossley Manor. The assessment ensures staff can meet the needs of the residents and provide the care required. The manager has improved the care files to ensure care needs are identified and staff have the necessary information to assist the residents. The care plan also records the aim and intervention by staff to ensure care is given according to need. The completion of risk assessments enables residents to retain their independence where possible. This is undertaken with the support of staff. Monies held on behalf of a resident are paid into a resident account. Mr Latif makes withdrawals, when the resident requests the money. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 8 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.V340049.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed to ensure the staff can provide the care and support they require. EVIDENCE: Assessments were viewed for two new residents who were admitted since the last inspection in November 2006. The assessments are carried out with as much input from the resident or their representative, where possible, to ensure all care and social needs are assessed. The assessment identifies key areas including mobility, diet, elimination, social background, medicines, dexterity communication, psychological state, safety, sleep and personal hygiene. This ensures staff have a good knowledge of residents’ needs. Residents’ are asked about their feelings with regard to coming into a care home to enable staff to alleviate any fears or worries. A transfer letter from a hospital was seen in one file to assist staff with collating information for the assessment. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 10 A resident confirmed that they came to the home to have a look round and were made welcome by the staff. The manager encourages prospective residents and their families to visit the home as often and for as long as they wish prior to the resident deciding whether to take up residency. Residents are offered a four week trial to enable them to view the accommodation, meet staff and other residents and get an over view of the service. Standard 6 was not assessed, as intermediate care is not provided. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are placed at risk, as medicines are not administered safely to them. EVIDENCE: As part of the case tracking process five resident care files were examined. These included residents of varying ability and needs. The manager has improved the recording of care needs and the care planning process is now more consistent. This benefits the overall care provision for the residents. The care files were organised and the information easy to read. Each file contained a plan of care based on individual need with detail of the aim and action plan to enable staff to give the right level of care and support. Key areas included mobility, diet, sleep, communication, personal hygiene and care of skin. Care documentation had been reviewed regularly to ensure the care recorded was accurate and relevant. Although care plans do not record person’s individual care needs according to religion and relationships staff interviewed were aware of residents’ needs in relation to these areas. Care Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 12 plans could be developed further to include this detail. Supporting care documents include risk assessments for nutrition, moving and handling, bathing, care of skin, risk of falls and residents who wish to administer their own medicines. The risk assessments had preventative and control measures in place to identify and minimise the risk to the resident. One care file evidenced a care review with a relative however the other files did not evidence consent to the care provision by the resident and /or their representative or family member. Through observation and discussion with residents and staff it was evident that care was being provided according to need and that the staff assist people to maintain their own independence where possible. Residents have access to a GP and other health professionals. District nurses provide clinical input where needed and their care records were available in resident rooms for staff to read and be aware of current treatments. A resident said, “The staff get a doctor for me if I need to see someone urgently and the nurse comes to see me and help me”. A resident had received a diabetic review by an external professional, to ensure the condition was managed appropriately by the staff. Comments regarding the care provision include: “My sister gets phenomenal care in the home” (relative) “We get all the help we need” (resident) “Very good care all round” (resident) Medicines are not administered safely to residents. Not all medicine administration sheets (MARs) evidenced staff signatures for medicines administered and there is therefore a risk that the residents did not receive them. The requirement for safe administration of medicines has been raised at the last two inspections and in light of the findings at this site visit a pharmacy inspector conducted a pharmacy inspection on 31st July 2007. The details of the inspection are as follows: The quality of medication handling and recording within this service was poor. Medication was not always administered correctly or recorded accurately. This places the health and wellbeing of residents at risk of harm. Basic medication policies and procedures were available, but these did not cover all aspects of medicines management within the home. This meant that staff did not always have clear instructions in order to protect the health and wellbeing of residents. There was no written evidence to show that staff had undergone medicines management training or competence checks before being allowed to handle medication. Residents are better protected if staff responsible for handling, Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 13 recording and administration of medication have been trained and assessed as competent to perform these tasks. Written records of medication entering and leaving the service had been maintained, with quantities of medication brought forward from the previous month clearly recorded. There were no records of medication given to residents who chose to self-medicate. A sample audit of Medication Administration Record charts and stocks showed that sixteen residents had not been given their medication as prescribed. One resident had recently been discharged from hospital where a number of changes had been made to the medication. These changes had not been recorded accurately, resulting in the resident receiving the incorrect dose of six preparations for six days. Nine residents had not been given some of their medication at all, three residents had not had their medication as no stock was available and a further three residents had missed doses as staff had been unable to locate the stock. The health and wellbeing of residents is at serious risk of harm if medication is not administered as prescribed. Not all medication could be accounted for. There was no system in place to regularly audit medication stocks and records in order to assess the quality of the medication service offered. The health and wellbeing of residents is at risk of harm if such checks are not made. There were large quantities of dressings and blood testing strips present for people who no longer lived at the home. Some of these were out of date. Medication that had been prescribed for individual residents had been kept for use as homely remedies. This practice must stop. Medication prescribed for a resident must not be administered to any other person. Evidence was seen that some residents had chosen to self-medicate some or all of their medication. Written risk assessments had not always been carried out to assess the residents’ ability to self-medicate or individual risks associated with this practice. Controlled Drugs were stored and recorded appropriately. With regard to privacy and dignity staff were observed to assist residents in a discreet and sensitive manner with various aspect of their care. Staff knocked on private doors before entering and a staff member reported that she always asks whether a resident wishes to be called by their first name or surname. A male member of staff said that he would always ask female residents if they would prefer to receive help with bathing from a female staff member. A resident said, “The staff are respectful towards me and would never compromise my dignity”. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can choose how they wish to spend their day and are given wholesome nutritious meals according to what they would like to eat. EVIDENCE: Mossley Manor presents with a welcoming atmosphere. Residents interviewed stated that the routine was relaxed and that they could choose within reason how they would like to spend their day. A number of residents go out from the home either on their own or with family or friends. One resident was celebrating a birthday and was going out with the family for celebrations. Another resident reported that they enjoy going out on the bus and that the staff support them with this. Staff interviewed were knowledgeable regarding individual preferences in relation to care, activities and social arrangements thus ensuring the wishes of the residents were understood. At the time of the site visit the activities co coordinator was with the residents and musical entertainment was provided in one of the lounges. The entertainment also included reading poetry and some dancing. It was well Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 15 attended and a number of residents confirmed how much they enjoyed the singing. The activities co coordinator works sixteen hours a week and is assisted by care staff with the various arrangements. Events are advertised on a notice board and arranged according to what the residents would like. Residents’ preferred interests are assessed on admission and activities are recorded in an activity file to evidence their participation and their enjoyment. The social and recreational arrangements are very good and the activities coordinator is enthusiastic about her role. She has contacted a number of shops, clubs and football clubs who now give their support to providing social activities and interests for the residents. A resident takes charge of a sweet shop, which is offered to everyone at the home. There is a library on the first floor and a resident said it had a good selection of books. Activities include arts and crafts, foot spas, reminiscence, games, day trips; film shows, garden parties and events at a local church and another care home. A resident said, “The activities co coordinator is marvellous and we have things arranged all the time”. There have been no recent newsletters for the residents however the manager is looking to re introduce them, as they were a good way of telling everyone about the activities each month. One resident receives large print literature of news articles which they enjoy reading and another attends a local luncheon club. Residents are promoted to maintain their independence and chosen life style. Staff respect the wish of those residents who do not wish to participate in the lounge. The activities co coordinator conducts one to one sessions in residents’ rooms if preferred. The hairdresser was visiting and residents confirmed that this service is offered regularly. Members of the clergy visit to enable residents to continue to practice their own faith and Holy Communion is also offered. Local schools visit particularly at times of celebration and school children sing for the residents. The manager ensures contact with the local community is maintained where possible. The menu is based over four weeks and residents interviewed said that the food was good and plentiful. Two residents stated that the cook would always prepare an alternative if they did not like the main meal of the day and dietary preferences had been recorded in the kitchen. The menu however did not show a choice of meal and was not on display for resident to see. Four residents interviewed were unsure of what was being prepared for lunch and two said that they would like a copy of the menu. There was evidence of a good supply of fresh produce and fresh vegetables were served at lunchtime. The main meal looked appealing and was served hot from the heated trolleys. Most of the residents get together in the dining rooms for their meals. Some residents prefer to have their meals in their own room and this wish was seen to be respected by the staff. Comments from residents regarding the food include: Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 16 “We get a nice meal every day” “Good food” “The food is ok” “Lovely meals” “The cook has to prepare lots of food and it is normally very good” Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polices and procedures are in place to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The complaint policy is displayed in the entrance hall. This needs the new address of the Commission for Social Care Inspection in Crosby as the Liverpool office has now closed. The complaint log was viewed and this evidenced the manager’s investigation into a complaint receive June 2007. The complaint was dealt with within a timely and appropriate manner and the complainant satisfied with the response. Staff interviewed were aware of the complaint procedure and what to do should a resident or relative report a concern. A resident said, “I have no worries or anything to say, I would speak to Sam (manager) straightaway”. At the time of the site visit a complaint investigation took place in response to a complaint received earlier this month. The investigation was regarding lack of monitoring for residents who fall. The care files and accident record seen evidenced a written report of the falls in question and the care provided by staff, district nurse and hospital. The complaint was not upheld however it is recommended that an audit be conducted of falls. This would be beneficial Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 18 when reviewing falls risk assessments to ascertain if there is any pattern or further preventative measure that could be put in place. An abuse policy was available in the policy and procedure file and a number of staff recently attended a Protection of Vulnerable Adult training course in June 2007. A copy of Sefton and Liverpool’s Adult Protection Procedure was not available and this should be obtained for guidance. A staff member described the various forms of abuse and the whistle blowing procedure for reporting an alleged incident. The manager reported an alleged incident to social services earlier this month. It was evident that the manager and staff are aware of the correct procedures to be followed to safeguard the residents. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19,20,21,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall accommodation must be improved to provide residents with comfortable and safe accommodation. EVIDENCE: A partial tour of the premises was conducted. The main hall is spacious and has notice board with photographs of residents and newspaper cuttings relevant to the home. There is a large piano in the hall and an attractive stained glass window leading up to the first floor landing. The hall and landing carpets are now becoming worn and the hall carpet has number of small stains, which cannot be removed. These will need to be replaced with time and should be included in the overall maintenance plan for the premises. There is a hairdressing room on the ground floor. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 20 The bathrooms have aids to assist residents and they were found to be clean and odour free. One bathroom is domestic in style. The shower room on the first floor is currently not being used for showering as there is broken tile and the shower surround is loose and poses a health and safety risk. Residents still use the toilet in this room and may well hold on to the loose surround. This must be mended to ensure their safety and to offer them a choice of bathing facilities. Bedrooms seen had personal items from home including pieces of furniture, pictures and ornaments. Bedroom doors have a lock and residents can have a key if they so wish. The manager stated that there is an ongoing programme for redecoration and a number of bedrooms have been decorated. There was no written evidence to support this and completed work should be recorded. Many of the bedrooms are old in style and could do with new pieces of furniture. Two carpets need to be replaced as they are badly marked and these were identified at the time of the site visit to the manager. The replacement of carpets will improve the standard of accommodation for the residents. There is a sun deck on the roof of the home. This is currently closed as pest control, are removing a wasp nest. There is a good sized garden at the rear of the premises and also to the front. Car parking facilities are also available. The rear garden has some furniture and residents can sit out in the warmer weather. It is also used for the summer garden party. The laundry room was tidy and organised. Staff have access to gloves and aprons. COSHH (Control of Substances Hazardous to Health) data is available on products in use and staff receive infection control training. This helps ensure the well being of the residents. Two residents interviewed stated that they liked the accommodation as it was ‘homely’ and kept clean. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are now recruited through robust recruitment procedures and there are sufficient numbers of trained staff to provide care and support to the residents. EVIDENCE: The staffing rota for the month of July 2007 was viewed and this showed sufficient numbers of staff on duty to care for the residents. Staffing levels are consistent to allow for a good level of interaction between residents and staff for the provision of care and social time. Staff were spending time with the residents in the lounge joining in with the musical entertainment. Residents interviewed commented on the fact that staff were polite, helpful and good at their jobs. A deputy manager/senior carer supports the manager to ensure continuity of management. Care staff are appointed a key worker role, which gives them more responsibility for a number of residents. NVQ (National Vocational Qualification) Level 2 and Level 3 are provided for care staff. There are currently seven care staff undertaking an NVQ course and 35 of staff have obtained an NVQ. Three staff files for staff recently appointed were examined. There was evidence of completed application forms (with details of past employment), Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 22 two references and police checks. The staff started prior to two references being received and these should be obtained before they commence employment. The manager stated that a number of recruitment checks for staff were missing prior to her appointment and that she is working through the files to ensure the necessary information has been obtained. Two files were examined for staff who were employed in 2005. One reference needs to be obtained for one staff member and this was brought to the manager’s attention. A recruitment, equal opportunities and sexual harassment policy help protect the welfare of staff. Staff files viewed evidenced an induction. This needs to be given in accordance with the Skills for Care Induction Standards to ensure staff are compliant with the national standard. Two staff interviewed said that they were shown round the premises when they started, had worked with a senior carer during their first week and not left to work unaided. The manager provides a training programme in safe working practices; this includes infection control, first aid, health and safety, food hygiene and moving and handling. Certificates were in staff files to evidence their attendance and there is also a training matrix. Five staff require moving and handling and this is planned to take place by the end of August 2007. A specialist course in pressure area care has also been arranged. Staff interviewed confirmed the courses they have attended this month and said that they are offered regular training. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed effectively, and run in the best interests of the residents. EVIDENCE: The manager Mrs Yeadon has been in post since 2006. Mrs Yeadon holds the Registered Manager’s Award and has commenced NVQ Level 5 in Management. Staff spoke positively regarding her leadership skills and said that she was consistence and fair in her approach. A resident reported, “Sam (manager) is very nice to talk to and very helpful”. Quality assurance systems are in place to ensure residents can give their views of the service. Residents were last given satisfaction survey forms in March Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 24 and May 2007 and those seen reported favourably regarding various aspects of the home. A resident meeting was held in April 2007 however no residents attended. A resident interviewed said that they could speak to Sam (manager) at any time and did not feel meetings were needed. Mr Latif, one of the owners, carries out a monthly visit of the home and completes a report of his findings. A report was seen for June 2007 and this evidenced meetings with residents, staff and an overall view of what had been going on in the home. A financial record was viewed for a resident. The record was amended at the time of the site visit to include further details to ensure the resident’s financial affairs were protected. Mr Latif stated that the account was not a business account for trading purposes. General staff meetings are held and also senior carer meetings. Minutes were seen of a meeting held in May 2007 and staff interviewed stated that they could meet with the manager at any time. Staff receive supervision to enable them to discuss their training, their care practices and the needs of the residents. Records were seen to be appropriately stored. It was however noted that a number of care records were not accurate in the fact that they did not always evidence the actual date of their completion, month only was stated. Staff have access to a good number of policies and procedures and these had been reviewed in May 2007 to ensure their accuracy with current legislation. A number of policies were seen including, confidentiality, accident reporting, infection control and health and safety. Policies regarding ageism, race, sexuality and disability ensure the rights of the older person are protected, they are treated fairly and their diverse needs are understood and met by the staff. Fire prevention equipment is subject to an annual safety contract and also the fire logbook showed that fire alarms are tested weekly. Staff receive fire awareness training ‘in house’ and this needs to be given to nine members of staff as the fire training list did not evidence their attendance of the training in April/May 2007. The fire risk assessment of the premises has yet to be completed to ensure the premises are safe for people to live in. A spot check was undertaken of the gas, electric and lift certificate for the home. Certificates seen were valid to ensure the ongoing protection of residents and staff. Accidents are recorded in the accident book and these were looked at with regard to the complaint investigation of residents falling. Satisfactory information had been recorded to evidence incidents that affected residents’ welfare. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 25 Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 26 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 3 2 Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13(2) Requirement Timescale for action Staff must administer medication 31/08/07 in accordance with the prescribers’ instructions so that people who use the service receive the correct amount of medication at all times. Requirements regarding medicine administration remain outstanding from two previous inspections. Timescales of 31/07/06 and 31/12/06 not met. 2. OP9 24(1) There must be an effective system in place to audit medicines management within the service in order to ensure that people who use this service are receiving the correct medication. Risk assessments must be carried out for all residents who self-medicate some or all of their medication in order to ensure they are able to look after and take their medication safely. Records should be kept detailing when medication has been DS0000025193.V340049.R01.S.doc 31/08/07 3. OP9 13(2) 31/08/07 Mossley Manor Version 5.2 Page 28 passed to these individuals. 4. OP19 16 (2) (c) The registered person must replace the carpets identified at the time of the site visit to improve the standard of accommodation for the residents. The registered person must repair the shower surround and tile to make safe the shower for residents to use. The registered person must make arrangements for persons working at the care home to receive suitable training in fire prevention. This will protect the residents. 07/09/07 5. OP21 23 (2) (c) 31/08/07 6. OP38 23 (d) 31/08/07 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 OP9 Good Practice Recommendations Out of date and waste medication should be disposed of promptly. Staff should receive appropriate medicines management training and have their competence checked prior to undertaking medication administration and recording in order to protect residents. The menu should be displayed for residents to view and an alternative should be recorded to promote choice for the residents. The manager should obtain a copy of Sefton and Liverpool’s Guide to the Protection of Vulnerable Adults for staff referral. NVQ training for staff should continue to achieve a ratio of 50 trained member of care staff with an NVQ Level 2 in care. References for staff should be obtained prior to them commencing employment. DS0000025193.V340049.R01.S.doc Version 5.2 Page 29 2. 3. 4. 5. OP15 OP18 OP28 OP29 Mossley Manor 6. 7. OP37 OP38 Records should evidence actual date of completion, not date only to ensure their accuracy. The fire risk assessment should be completed to ensure the premises are compliant with fire regulations. Mossley Manor DS0000025193.V340049.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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