Inspection on 24/05/07 for Mother Redcaps Nursing Home

This inspection was carried out on 24th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mother Redcaps Nursing Home 27/10/09

Mother Redcaps Nursing Home 29/06/08

Mother Redcaps Nursing Home 04/12/06

Mother Redcaps Nursing Home 19/05/06

Mother Redcaps Nursing Home 21/12/05

Mother Redcaps Nursing Home 16/05/05

Mother Redcaps Nursing Home 21/10/04

Mother Redcaps Nursing Home 19/07/04

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 Mother Redcaps Nursing Home Lincoln Drive Egremont Promenade Wallasey Wirral CH45 7PL Lead Inspector Julie King & Paula Smithson Key Unannounced Inspection 09:00 24th May 2007 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 Mother Redcaps Nursing Home DS0000020940.V336432.R02.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. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mother Redcaps Nursing Home Address Lincoln Drive Egremont Promenade Wallasey Wirral CH45 7PL 0151 639 5886 0151 630 1730 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) Mary George Limited Janet Nixon Acting manager Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51), Physical disability (2) of places Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A maximum of 51 older persons may be accommodated of whom no more than 2 adults shall be in the category PD and two named adult under 65 years of age. Provide accommodation for two named service users for personal care OP (PC). One named service user under age of 65 years. Three named adults in Category OP (N) under the age of 65. Date of last inspection 4th December 2006 Brief Description of the Service: This care home is a three-storey purpose built nursing home, situated on Egremont Promenade overlooking the river Mersey, and offers nursing care for 51 older persons. A lounge/dining room is provided on each floor with televisions, videos, piano, and music centres available. The home is double glazed throughout and ramp access is available at the front entrance. A lift serves all floors. All accommodation offered is in single rooms and the majority have the benefit of en-suite facilities. A selection of bathrooms, showers and toilets are provided on each floor and assisted bathing facilities are available. The small front and side gardens are well maintained and car parking is provided at the front of the building. Fees range from local social service rates to £481. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over a day at the home. Prior to the visit a number of questionnaires had been sent out to relatives and visitors. During the visit some members of staff, residents, management and multidisciplinary healthcare team (MDT) members were spoken to. All areas of the internal environment were also inspected. Documentation, especially resident’s care files and medication administration records were examined. What the service does well: What has improved since the last inspection? What they could do better: Ongoing improvements are required in all staff personnel files, staff training & development, supervisions & appraisals. The cleanliness and environment need more work to be fully compliant, and quality assurance processes still require improvement in all areas. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 6 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. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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 Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 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 about where they wish to live and can be confident that their needs will be assessed and met. EVIDENCE: Since the previous site visit most residents care files have been re-written using up to date documentation. Examination of a random selection of residents care files demonstrated that an appropriate assessment of needs had been carried out prior to admission. One person stated “I lived in another home before coming to live here. But staff wanted to know what I was interested in doing and what was important to Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 9 me if I came to live in Mother Redcaps. I told them and they have since supported me in doing what I like to do”. The pre-admission assessments seen contained the information needed to construct an initial plan of care and those seen had been completed with the assistance of the resident’s family or representative. As part of the examination of evidence relating to this site visit, the professional views of a GP and a specialist nurse were obtained regarding how the care home addressed the needs of the residents. Both professionals spoken to expressed no concerns re current levels of care delivery, and were complimentary of the nursing and care staff. Training in all mandatory areas was seen to be in process for most staff, and some staff have also completed resident-specific training and development in areas such as wound care, continence, etc. Visitors and prospective residents confirmed that they were welcomed at the home to visit at any time and as often as they wished when deciding whether to request or accept a place at the home. The home also offers trial stays with a view to permanent residency subject to availability. Intermeidate care is not provided. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a care planning system in place for all residents. This provides staff with most of the information they need to meet the resident’s needs. EVIDENCE: A range of care plans and associated documentation were examined during this visit. These included residents with differing needs such as sensory impairment, specialist nursing needs and varying levels of cognitive ability. All the care plans and associated documentation seen had been updated with a more comprehensive care planning tool. Also the standard of recording had improved with written comments by the qualified staff reflective of the care delivered in accordance with the plan of care. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 11 Multidisciplinary healthcare team involvement was apparent, as were timely referrals as needed to the tissue viability nursing service, speech & language therapies, GPs, etc. The risk assessments seen evidenced an improvement, and were far more wide ranging in content. Evidence of resident’s signatures and involvement in their care planning process plus input of relatives and representatives was seen. Medications were examined and found have significantly improved in all areas of management and administration, and on the day of this site visit were found to be in accordance with current good practice guidelines and requirements. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is adequate. 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, but limited social and recreational activities do not promote independence and individuality for each resident. Meals at Mother Redcaps are good, offering choice and variety whilst catering for residents dietary needs or cultural preferences. EVIDENCE: Residents in the home are asked on admission about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. Currently the managers are recruiting for an activities co-ordinator, but in the meantime care staff (with the assistance of a physiotherapy assistant once per week), are doing their best to facilitate and accommodate resident’s choices of activities as far as possible. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 13 The residents informed the inspectors that they enjoyed the variety of food in the home. Comments such as “if I don’t like what’s on the menu I can choose from a selection”, “The puddings are my favourite meal”, “ Though I don’t feel like eating, the chef always try’s and make’s something tempting for me”. Meals at mother Redcaps are varied and include a large proportion of homemade dishes and pastries. The kitchen is well equipped and organised and the stores are well stocked. Meals are taken either in individual rooms or one of two communal dining areas. Mealtimes and the midday meal in particular is an opportunity for mobilisation and social interaction and every encouragement should be given to residents to participate. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be sure that their complaints will be taken seriously and acted upon in an appropriate manner. Residents are not fully protected from abuse, which places them at risk of harm or injury. EVIDENCE: There is now a record of complaints and actions taken at the home, and the managers ensure that all complaints verbal or written are documented together with details of appropriate investigations and outcomes to promote openness and transparency. It is recommended that the complaints procedure be reviewed and distributed to all residents or their representatives. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 15 The protection of residents from abuse of any sort must always be paramount and the home must ensure that all staff members are trained in abuse recognition and the actions to take should abuse be discovered or suspected. The home is currently in process of providing this training and must complete training in adult protection as a priority. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment at Mother Redcaps needs ongoing improvements in order to promote a homely, safe and comfortable place to live for the residents EVIDENCE: Resident’s rooms are personalised to varying degrees depending upon individual wishes and are encouraged to live with their own possessions around them. One person had brought in various aids to assist them around their room and make their stay enjoyable and another person had used a theme to personalise their room to their taste. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 17 Some rooms were noted to be malodorous and it is recommended that if regular cleaning is failing to control the odour then the home should look at alternative flooring. Furnishings are of an adequate standard in most parts of the home, and a number of items have been replaced visit including armchairs. Two people to assist in their comfort and independence have brought furnishing into one of the main lounge areas which one person was pleased to be able to have done. Maintenance in the home is ongoing with two out of the three main corridors and floor being redecorated to varying degrees. The top floor was in process of redecoration and during this visit, with most areas on the plan to receive attention. The gardens have been tidied but require ongoing maintenance if they are to remain user-friendly and safe for residents. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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. 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. Recruitment procedures are not yet fully compliant therefore fail to fully protect the residents. EVIDENCE: Examination of the off duty records shows that on the day of this site visit there appeared to be sufficient staff to meet resident’s needs. The home is reminded that the level of care required and dependency of residents must be based on comprehensive assessments of need and that the needs of residents with dementia increases over the course of the day and staff must always be available to meet those increased needs. The home does not meet the 50 target for staff with a minimum of NVQ2 and staff members need to be supported and facilitated to gain the qualification. However staff have undertaken various training courses organised and arranged at the home to ensure they are trained and competent to do their jobs. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 19 The staff personnel files evidenced improvement, with the majority of files seen now most of having the required documents and records, but work is still needed in order to fully comply with requirements. The home must review staff personnel files and ensure that all the required information and documents are obtained, including details of staff inductions and risk assessments were appropriate. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is effective management, guidance and leadership at Mother Redcaps helping to ensure the health, safety and welfare of residents. EVIDENCE: The new manager at Mother Redcaps is a first level nurse and has many years nurse management experience. She has commenced the process of registration with the CSCI, and has obtained her Registered Manager’s Award / NVQ4 in Management. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 21 The new manager has made significant improvements to this service in a very short period of time, and the overall quality and detail of the records examined evidences compliance or near-compliance in most areas. Comments made from people who live at the home were positive about the new manager and made comments such as “Things are changing for the better”, “Staff know what to do when I ask them, its down to that manager”. Staff stated “I feel supported”, “I am told about peoples care and what they need”. The limited amount of quality assurance that was present at the previous visit has been taken forward but requires more detail and work to meet the required standard. Records are securely stored and held in accordance with the Data Protection Act. There has been training in the mandatory areas for fire awareness, first aid, manual handling and health and safety. However all staff must complete the training in these areas as a priority to ensure they are aware of safe working practices and that the health, safety and welfare of service users are promoted and protected. Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 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 X X 3 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16(2)(n) Requirement The registered person shall having regard to the size of the care home and the number and needs of service users consult service users about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation. Timescale for action 31/07/07 2. OP18 13(6) The registered person shall make 31/07/07 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person must ensure that they obtain all the documents and records as specified in Schedule 2 of the Care Homes Regulations 2001 for all persons employed. The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home including the quality DS0000020940.V336432.R02.S.doc 3. OP29 19 31/07/07 4. OP33 24(10 31/07/07 Mother Redcaps Nursing Home Version 5.2 Page 24 of nursing where nursing is provided at the care home. 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 OP8 Good Practice Recommendations It is strongly recommended that all accidents, falls and untoward incidents are clearly audited and recorded by the homes management at least monthly. It is strongly recommended that the registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2. OP30 Mother Redcaps Nursing Home DS0000020940.V336432.R02.S.doc Version 5.2 Page 25 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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