Inspection on 31/01/06 for Mossley Manor

This inspection was carried out on 31st January 2006.

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 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 Unannounced Inspection 31st January 2006 09:30 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.V281459.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.V281459.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.V281459.R01.S.doc Version 5.1 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. 18th October 2005 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.V281459.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory inspection took place over a seven-hour period. A full tour of the premises was undertaken accompanied by the acting manager. 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.V281459.R01.S.doc Version 5.1 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.V281459.R01.S.doc Version 5.1 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): 1,3,4,5 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 Statement of purpose needs updating to reflect the changes that have occurred in relation to the changes in day-to-day management, incorporate the detailed complaints procedure and ensure that all of the information detailed in schedule 1 is included. Residents are only admitted to Mossley Manor following a pre-admission assessment. All pre-admission assessments are carried out by the homes acting manager and include direct input from the prospective service users’ family / representative and other health care professionals. 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. One resident Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 Page 8 admitted to the home has a primary diagnosis of dementia probably Alzheimer’s and in accordingly should have been assessed as EMI residential. When assessed before admission the acting manager was informed that the resident was suitable for residential care. The resident concerned has settled into the home but staff must be aware that a deterioration in both in cognitive ability and behaviour is inevitable and will require transfer to a more appropriate home. 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.V281459.R01.S.doc Version 5.1 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 Residents are not supported due to the lack of a clear and consistent care planning process in place to provide the information needed by care staff to meet the identified needs. Medication management is not fully compliant with current good practice requirements and guidelines EVIDENCE: Care records were examined for several residents. The last person admitted to the home had all the documentation in place but much had not been completed some two weeks after admission. Blank documentation included the risk assessments for mobility, falls, pressure areas, or a weight record whilst there were no details of nutrition or continence needs. The care plan was inadequate and did not reflect the assessed needs. A further three care files examined exhibited the same inadequate care plans, lack of risk assessments or inadequately completed or reviewed risk assessments. The care plans did not reflect the needs of the residents although the daily diary sheets indicated that in most cases appropriate care was being delivered. The inspector observed one resident being moved in a large armchair backwards with her heels banging on the floor as the chair was moved rather than having Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 Page 10 been transferred to a wheelchair for transfer. The care plan and associated risk assessments should have identified the correct equipment and method for transfer and this information passed to the staff. Evidence was seen that residents’ were referred to relevant NHS services such as G Ps’ and district nurses together with outpatient appointments. No residents in the home self medicate and self-medication would only be allowed following a risk assessment. On the day of inspection all drugs given were signed for with appropriate reasons given if a drug was not given. However drugs coming into the home either via the monitored dosage system or in between weekly deliveries are not being signed for as being received. All drugs administered were signed for without gaps but there was a lack of two signatures on handwritten scripts on the MAR sheets. There were no controlled drugs in use at the time of inspection. Temperatures of the clinical room downstairs and drug fridge are recorded daily but there is a need to record the temperature of the clinical room upstairs. Residents drugs returned to pharmacy are recorded, a date and signature from the pharmacy representative being obtained when returned. 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.V281459.R01.S.doc Version 5.1 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. It is strongly recommended that a dedicated activities co-ordinator be employed to develop the activities programme and particularly with regard to one to one activities for those residents who are unable to participate in the group activities. 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. Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 Page 12 A varied diet is provided with residents special dietary needs or cultural preferences being catered for. On the day of inspection the inspector observed the mid-day meal being served. The tables in one of the dining rooms had been laid for lunch but the debris from breakfast was still evident on the table. Residents have the choice to have their meals in their own room if they wish and the inspector observed meals being taken to residents without trays or plate covers although these are available in the home. 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.V281459.R01.S.doc Version 5.1 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 no complaints either directly to the home or to CSCI since the last inspection. 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 has recently been carried out for all staff. Staff spoken to demonstrated a good knowledge of adult abuse and recognising abusive practices. Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 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 inspection the front door was opened by a resident who whilst independent with regard to mobility and personal care appeared to be confused. The inspector was informed that the resident concerned had been resident at the home for several years and had been given the code to the digital lock to allow her to come and go freely. During the day the inspector observed the door opened by the resident on several occasions and people entering the home without anyone knowing. This is not an acceptable situation for the safety and security of all residents. A request was made for the code to be changed and restricted to staff members only. During the tour of the home the inspector made the following observations: Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 Page 15 Top floor bathroom extractor fan not working Rm 33 was very malodorous; sink unit broken and bedside cabinet badly stained. Top corridor carpet badly stained and worn Sluice room left open Top floor lounge chairs missing three cushions whilst other cushions had no covers and were just the plain foam Rm 33 sink unit needs repair Rm 40 light not working Rm 41 Door handle coming off Rm 42 Extractor fan not working Rm 32 Air cell mattress on bed negating use of bed rails as placed on full size mattress making bed too high. Requires provision of high bed rails. Middle dining room bin broken Rm 22 Broken toilet seat Lounge 3-way light switch on wall broken, use of multiplugs in sockets Slice room left open Rm 18 door automatic closure not working Carpet at entrance to shower room causing a trip hazard A number of rubbish bins throughout the home broken The inspector was informed that the homes handyman now comes for two days a week. It remains a recommendation 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. Toilet and washing facilities are adequate in number and appropriately located in relation to communal areas. Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 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 There are sufficient numbers of care staff employed to meet the needs of the residents but recruitment policies and practices remain poor 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 acting manager has NVQ 3. A qualified first aider is rostered to be on duty every shift. Recent training has included Pova and dementia. 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 previous inspection highlighted the lack of CRB, PovaFirst checks and the lack of references and the requirements were discussed at length with the homes manager at that time. Examination of the personnel files showed that care staff is still being employed without obtaining satisfactory references, CRB or PovaFirst checks. There is no TOPPS compliant induction programme in place Staff members spoken to stated that their recent training had been beneficial and were able to demonstrate a good knowledge of their roles and responsibilities. Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 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): 31,32,33,35,36,37,38 The management at Mossley Manor is ineffective with lack of guidance and supervision, which compromises the health, safety, and welfare of residents and staff. EVIDENCE: The home has been without a registered manager for some months and the acting manager who had only just be made deputy manager when the previous manager left does not have the necessary knowledge or experience to fulfil the responsibilities of the role fully. There is a lack of leadership and guidance and this is demonstrated in various ways not least the inadequate care planning. The acting manager informed the inspector that whilst she was doing her best, which is evident, she found things difficult because no one had shown her what to do or how to do it. Resident’s monies were checked and found to be correct with receipts kept for any expenditure. Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 Page 18 There has been no staff supervision or appraisals since October 2005. The registered person has been submitting monthly reports in accordance with regulation 26 but there has been a failure to recognise the situation. There is no other quality assurance system in place. Water temperatures have not been checked since October 2005 and fire alarm tests have only been carried out monthly rather than the required weekly intervals. Valid safety certificates or service contracts were seen for gas, electricity, lift, hoists and portable appliance tests. The inspector was unable to see evidence that the required 6 monthly Loler tests had been carried out on the lift or hoists. Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 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 X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 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 2 2 2 X 2 2 2 2 Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 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 all the items listed in schedule 1. 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 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 ensure that all identified actual and potential problems of each service user are clearly documented, relevant and up to date at all times. The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medications received into the care home Timescale for action 31/03/06 2 OP3 14 31/03/06 3 OP7 13 & 15 31/03/06 4 OP8 15 31/03/06 5 OP9 13(2) 31/03/06 Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 Page 21 6 OP19 23 7 8 OP19 OP26 12(1)(b) 16(k) 9 OP29 19 10 11 OP31 OP31 8 9 12 OP31 10 13 OP33 24 14 OP36 18(2) 15 OP38 13(4) 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 ensure that the home is secure at all times. 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 satisfactory references and valid CRB/POVA enhanced certificate, before being employed in the care home. The registered person must appoint a suitable manager to manage the home A person shall not manage the care home unless they have the qualifications, skills and experience necessary for managing the care home. The registered person must ensure that the care home is managed with suffucient care, competence and skill The registered person must ensure that a system is established and maintained the review and improvement which, provides for consultation with residents and their representatives The registered person must ensure that care staff receive appropriate supervision and appraisal at the required intervals The registered person must ensure that the lift and hoists have the required 6 monthly Loler tests and forward relevant DS0000025193.V281459.R01.S.doc 31/03/06 28/02/06 31/03/06 28/02/06 31/03/06 31/03/06 28/02/06 31/03/06 31/03/06 31/03/06 Mossley Manor Version 5.1 Page 22 certificates to the CSCI 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 Refer to Standard OP19 OP12 Good Practice Recommendations It is strongly recommended that the hours allocated to the handyman for maintenance of the home be reviewed. 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. Mossley Manor DS0000025193.V281459.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Liverpool Local 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.V281459.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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!