Inspection on 19/07/06 for Mowbray Nursing Home

This inspection was carried out on 19th July 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

Mowbray Nursing Home 21/09/09

Mowbray Nursing Home 05/08/08

Mowbray Nursing Home 07/02/08

Mowbray Nursing Home 06/06/07

Mowbray Nursing Home 25/01/07

Mowbray Nursing Home 09/02/06

Mowbray Nursing Home 08/09/05

Mowbray Nursing Home 10/02/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mowbray Nursing Home Victoria Road Malvern Worcestershire WR14 2TF Lead Inspector Chris Potter Unannounced Inspection 19th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mowbray Nursing Home DS0000063032.V304611.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. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mowbray Nursing Home Address Victoria Road Malvern Worcestershire WR14 2TF 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) 01684 572946 Minster Care Management Limited Miss Joanna Kate Baines Care Home 39 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (39), of places Physical disability (1), Physical disability over 65 years of age (39) Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Mowbray Care home is situated in Malvern, being convenient for local amenities and public transport. The home is a large converted house set in spacious grounds with views of the open countryside. The home is owned by Minster Care Management Limited. The registered manager is Ms K Baines who is a first level registered nurse. The home is registered to accommodate 39 residents with both nursing and residential needs. Residents have a choice of either single or double bedrooms, many benefiting from having en-suite facilities. Other facilities provided for residents include lounges and a dining room. Passenger lifts are available to enable residents who possess mobility problems access to the first floor of the home. The fees for this home range between £432.00 - £560.00, this depends on the size of the room and whether it is shared or single accommodation. Hairdressing, chiropody, newspapers and the cost towards some outings are additional to the fees. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The homes key unannounced inspection started on the 19th July 2006, and was undertaken by two inspectors from the CSCI office. The second visit was conducted on the 31st of July 2006, by one inspector from the CSCI. The total hours of inspector time was 14 hours. The last inspection for Mowbray took place during February 2006. At the time of the inspection the home was caring for 36 residents plus four on the intermediate unit. This inspection focused on the requirements from the last inspection and monitoring the home against the key standards. The methodology used was a review of records and registers, a tour of the environment, case tracking the care of three residents, and the management of medication. Residents, staff were spoken with to establish their views about the home. Feedback was also received from other professionals using the home and relatives. The inspectors were disappointed with the homes progress to meet the requirements from the previous inspection and bring the home forward. Concerns were raised by the inspectors about the failure of the home to address recommendations from: • The gas safety inspection, • The safety checks of the hoists, • The requirements from the electrical inspection, • The recommendations from the legionella risk assessment. • The shaft lift inspection report. What the service does well: Social activities have continued to improve and the activities co-ordinator is enthusiastic about her role. The activities co-ordinator holds meetings with the relatives and residents to discuss any issues and these meetings are minuted. It was noted that it is the same people who participate. Many of the resident’s bedrooms have been personalised by the resident, which gives a more homely environment and reflects their personality. The choices and quality of the food provided at the home is good, and residents were most complimentary. The management of medication is well organised. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should ensure that the recommendations following servicing of equipment and systems are addressed. Failure to do could result in potential health and safety issues for residents, staff and visitors to the home. Care plans need to be further developed to ensure that they accurately reflect the residents care needs appropriately. Staff training to ensure all staff are appropriately trained to meet the needs of the residents. A staff supervision program should be introduced to monitor care staff and their performance. The home must ensure that they follow their recruitment policy to further safeguard the residents. The need for the home to clarify the staffing levels on the intermediate unit should be reviewed to ensure that the home is meeting their contractual agreements. A redecoration and refurbishment program is required to enhance the homes appearance and review the existing facilities are adequate for the residents assessed needs. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 7 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. Mowbray Nursing Home DS0000063032.V304611.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 Mowbray Nursing Home DS0000063032.V304611.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 The outcome for this area is good. This judgement has been made using available evidence including visits to this service. Residents’ individual needs are assessed prior to them moving into the home in order to establish the home’s ability to meet those needs, and to help ensure appropriate care is provided. Potential residents are provided with the appropriate information to assist them with their choice of home. EVIDENCE: The home provides prospective residents and relatives with a copy of the homes Service User’s Guide and a copy of this is available in the resident’s bedrooms for reference. Relative’s feedback confirmed that they had been provided with the appropriate information to assist them in choosing the home. It was confirmed they had also been invited to visit the home prior to confirming their choice. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 10 A contract detailing the terms and conditions of the home are provided on admission to the home a copy is retained by the home. The manager usually visits the potential resident prior to admission and completes a pre-admission assessment to ensure the home is able to meet the needs of the residents. A resident admitted to the home confirmed they had been assessed prior to admission to the home. Comments from residents included, “Staff are very nice and polite”, “Very pleased with the care”. Residents also stated that they were pleased with their bedrooms. The home provides an intermediate unit and as a contract with the PCT for this. It was recommended that the Registered Provider review their contractual agreement and the number of staff that are allocated to the unit. At the time of the inspection only one member of staff was covering the unit. When assistance is required staff from the home are called upon leaving the levels short in the home. Mowbray Nursing Home DS0000063032.V304611.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,and 10 The quality outcome in this area is adequate. This judgement has been made using available evidence including visits to this service. Care plans and risk assessments were insufficient and inconsistent in that they did not give the necessary detail regarding residents care needs to ensure that care staff are able to provide the level of input required. This shortfall can leave residents at potential risk. EVIDENCE: Care plans for four residents were reviewed at the time of the first visit. These showed some improvement with the formatting since the last inspection. Significant shortfalls were identified with the lack of information recorded on the residents care documentation record. The home must ensure that residents care records are reflective of the residents assessed needs. The detail should provide directions for the staff to deliver the care to the residents. Risk assessments should be developed into a care plan to assist staff in meeting those assessed needs appropriately. One care plan failed to evidence any care needs. The home was requested to forward a care plan within 24 hours for that Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 12 resident. This was addressed by the deputy manager and the plan received by the CSCI. The second day of the inspection was undertaken on the 31st of July 2006. Staff confirmed the time and work that had gone in to improve the residents care documentation. A care record was reviewed and the residents care, case tracked, this plan was reflective of their care needs. Feedback received from other professionals, relatives and residents were most complimentary about the care provision at the home. Comments received included “excellent care”, “No complaints with the home”, “Very pleased with the care”, The systems for the administering and recording of medication was reviewed and found to be well organised at this inspection. The requirements from the last inspection had been addressed. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 13 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 and 15 The outcome for this area is adequate. This judgement has been made using available evidence including visits to this service. Activities are available and the residents’ choice, and capabilities are catered for. The dietary needs of residents are met; the home must ensure residents requiring assistance with feeding is provided. EVIDENCE: At the time of the inspection residents were in the lounge, and their bedrooms. The residents in the lounge were watching the television; no staff supervision was present in the lounge at the times of the visits. Some of the residents spoken to confirmed it was their choice to stay in their bedrooms. They also stated that they were pleased with their bedrooms and the outlook from the bedrooms. Activities are being reviewed and developed by the activities organiser, and a good record is included in the residents care documentation. Some activities are one to one depending on the residents needs. One resident was participating in a board game, but stated this was because the home was short staffed. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 14 On the first day of the inspection the activities organiser was providing nail care for some of the residents. A summer fete was being organised for the home to include a pig roast. A list of activities are displayed in the entrance of the home. Relatives are able to visit at any time, and relatives were observed visiting at various times during the days of the inspection. The daily routine was discussed with some residents to establish if they have a choice of what time they get up and what time they go to bed. Some residents confirmed they were woke up early for breakfast. The reason for this when requested was because the night staff do breakfasts and this has been the routine for several years. This should be reviewed to ensure that residents are provided with a choice of having breakfast at a reasonable time to suit them. Assistance for residents at meal times should be reviewed. A resident was observed still trying to eat a cold meal at 15.20pm. The pudding was also on the tray and had not been started. A system should be in place that residents requiring assistance are ensured that their meal is kept warm until assistance is available. The practice of serving the dinner and pudding together should be reviewed to ensure the pudding stays warm. The catering provision for the home appeared well organised. The menus rotate every 4 weeks. The menus are available in the entrance of the home for visitors to view. Residents are offered a choice of food for the following day. On the day of the first visit the home was providing beef stew plus vegetables or sweet and sour chicken and rice. Followed by strawberry cheesecake, fresh fruit, cheese biscuits or ice cream. Residents were complimentary about the choice and quality of food. Comments included: “The food is generally good”,” The food is very good”, The catering staff cater for dietary likes and special diets. On the day of the inspection the waste disposal unit was broken. Some requirements from the gas servicing and Environmental Health Department have not yet been actioned by the Registered Provider. The Kitchen is in need of upgrade and a redecoration program. Catering staff are completing appropriate records, registers and the cleaning rota was seen at the visit. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 15 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 and 18 The outcome for this area is adequate. This judgement has been made using available evidence including visits to this service There is a complaints procedure in place to fully safeguard the residents. However, the complaints procedure must be adhered to. EVIDENCE: The homes complaints records were reviewed at the time of the inspection. From the register it would appear that not all the complaints are being recorded and investigated appropriately. One complaint made about the laundry had not been recorded. A complaint relating to a member of staff was also not included in the complaints register. Residents were generally aware about the complaints procedure. One resident felt that issues were not addressed as they used to be, the rationale for this was that the manager does not go round and speak to the residents every day. The home must ensure that all complaints are recorded appropriately and the outcome of the investigation undertaken is evident. No complaints have been made directly to the CSCI in respect of this service. There has been no allegations of potential abuse since the last inspection. All staff should receive training to ensure that they understand the various types of abuse. The contents of the whistle blowing policy and their responsibility to report any concerns they may have. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 16 Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 17 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 and 26 The outcome for this area is poor. This judgement has been made using available evidence including visits to this service. Although many areas of the home are acceptable other areas are in need of redecoration or repair in order to provide an environment that is homely and safe to live in. Some of the structural areas and facilities of the home are not suited for the category of residents. EVIDENCE: The home is conveniently located in a residential area of Malvern. Conveniently located for visitors using public transport. It is a large home providing accommodation for 39 residents. The home stands in large spacious well maintained gardens that provide a pleasant outlook. The inspectors were advised that the home is hoping to provide an enclosed rear garden for the residents to use when the weather permits. The homes appearance would be Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 18 improved from a redecoration and refurbishment program. Some bedrooms had been painted since the last inspection, however this is a very slow process, as rooms can only be decorated when they are vacated. Some structural changes would assist residents to access areas of the home with ease. The corridor on the ground floor is narrow, and staff confirmed it is difficult to manoeuvre residents in wheelchairs through this area. The bathing and shower facilities must be reviewed as they are not suitable for the needs of the residents. The lounge near the dining room on the ground floor is not homely, it was recommended that this would be better used for the dining room, and the lounge be transferred to the dining area. The lounge and dining area was in need of redecoration and new chairs should be provided. Many bedrooms have been personalised by the resident this reflects their personality and provides a more homely atmosphere. Residents spoken with during the inspection confirmed that they were pleased with their bedrooms. A window on the ground floor over the fire escape with a large drop, was requiring a window restrictor to further protect the residents. The home was reasonably clean throughout; some odours were evident in some areas the source of these should be investigated especially on the ground floor. Storage facilities should be reviewed in the home there appeared to be storage problems with incontinence pads and wheelchairs. A new sluice has been provided since the last inspection, this is commended. The bedrooms with the low glazing need some protection to reduce the potential risk of accidents to residents. The home must ensure that the extractor fans are in working order to reduce the odours permeating around the home. It was recommended that the use of the rehabilitation kitchen be reviewed. Staff reported that occupational therapy assessments are not being carried out as the kitchen is being used by residential staff. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 19 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 and 30 The outcome for this area is poor. This judgement has been made using available evidence including visits to this service. Staffing levels should be reviewed to ensure that residents’ safety is maintained. The recruitment procedure should be followed to ensure the protection of the residents. EVIDENCE: Given the high dependency of the residents and the size of the home, staffing levels are only within the minimal recommendations until 1400pm and fall below the minimal recommendations after 1400pm until 2000pm. Given the majority of residents are nursed in their bedrooms and the lay out of the home this should be reassessed. It was observed that there was no staff supervision in the lounge on the days of the inspection. The care documentation had not been kept up to date. Staff assisting on the intermediate unit when rostered for the home. Some residents commented that they wait a long time to have their buzzer’s answered. The resident still trying to eat her lunch at 15.20pm. A resident informed the inspector that because there was not enough staff they could not do the planned activities. It was also of concern to be advised that the home does not provide laundry and housekeeping staff at the weekends, Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 20 leaving this to the care staff. These are indicators that the staffing levels should be reviewed especially around peak times. Staff training records were reviewed which evidenced that not all staff were up to date with their mandatory training. These included moving and handling some were recorded as 2003 and 2004. This was of concern as a couple of accidents to residents had recorded caused by hoist. No specialised courses had been provided for the nursing staff. The home must also ensure that a trained first aider is on duty to cover the 24-hour day. A random selection of three staff personal files were reviewed at the time of the inspection. These evidenced that the home had not followed their recruitment procedure fully issues highlighted from these included: • • • • • Poor employment history The gaps in employment not explained One reference in some cases not the most recent or current employer. No evidence of the training or qualifications prior to starting work at the Home. Staff commencing work prior to the home receiving confirmation from Protection of Vulnerable Adults or Criminal Records Bureau first. Examples of this included a staff member commenced 22nd May 2006; the POVA first was not received until 12th June 2006. This was the same for the three staff files reviewed. References were either old or from a friend, and not the most recent employer, this must be addressed to safeguard the residents. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The outcome of this area is poor. This judgement has been made using available evidence including visits to this service. Improvements are necessary to the overall management of the home to ensure positive health and safety practices are promoted and accurate records are kept. EVIDENCE: The manager is a first level registered nurse, who was appointed in January 2006. The manager is currently working towards the NVQ level 4 qualification that is a requirement of the registration. Some comments received from residents and staff indicated that the manager was not fully able to delegate staff to deliver the care. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 22 The home is in the process of auditing their systems the registered providers have employed an area manager to undertake this. The area manager is also providing support and advice to the home. The staff confirmed that this had been of great benefit to them. The home hold regular staff meetings, these are poorly attended by the staff. Residents finances are not managed by the home, their relatives tend to manage them on their behalf. The home keep small amounts of money for hairdressing, newspapers and this is being appropriately managed. A staff supervision program for all staff as yet to be introduced. This should cover all aspects of practise, philosophy of care and career development needs. Some serious concerns were raised in respect of health and safety in that the registered providers have failed to address requirements from servicing. The registered providers must provide confirmation to the CSCI that these areas are being addressed. Areas requiring remedial work were: • • • • • • The lift, servicing reports from January 2006 highlighted work to be undertaken. The five-year installation report from March 2006, some remaining work to completed. The gas safety certificate requirements had not been actioned. Recommendations from the legionella had not been followed. A hoist requiring attention following servicing to the leg adjuster had not been fixed. The Environmental Health officer’s requirements from their visit in May 2006 had not been addressed. Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 1 3 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 1 2 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 3 3 1 2 1 Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 24 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 OP4 Regulation 14 (1) Requirement The home must provide staff with the relevant competencies to meet the care needs of the residents admitted to the home The home must review their intermediate care unit to ensure that they are meeting their contractual requirements. The home must ensure that a plan of care is developed to accurately reflect the residents risk assessments and care Timescale for action 30/10/06 2. OP6 13 31/08/06 3 OP7 12 (1) a 31/08/06 This remains outstanding from last inspection. 4 OP8 12 (1) a Residents care plans must cover all aspects of health care needs and identified risks must be assessed and acted upon. Remains outstanding from the last inspection. 31/08/06 5 OP14 12 (1) a 6 OP15 15 7 OP15 15 The home must ensure that the resident’s wishes on the time they get up and go back to bed are followed as much as possible. The home must ensure that the residents requiring assistance with their meals are provided appropriately. The home must review keeping DS0000063032.V304611.R01.S.doc 31/08/06 31/07/06 31/08/06 Page 25 Mowbray Nursing Home Version 5.2 8 OP16 16 (3) 9 OP18 12 (1) 10 OP19 23 (1) 11 12 13 OP20 OP21 OP22 16 (1) 23 (2) 23 14 OP26 13 the meals warm, and serving hot puddings after the resident has finished their lunch. The home must maintain a record of all complaints received and details of the investigation and any action taken. The home must ensure staff are appropriately trained in protecting vulnerable adults, and all allegations and incidents of abuse are followed up promptly, and records are available of the action taken. The home must provide the CSCI with a plan to identify how the home is to be upgraded and provide appropriate timescales for this. The home should review the furnishings to further enhance the homes appearance. The home must ensure that bathrooms are appropriate for the residents assessed needs. The home must ensure that appropriate storage is available for items such as, pads and wheelchairs. All marked, stained or fatigued carpets must be cleaned, repaired or replaced. Remains outstanding from last inspection. 31/07/06 30/10/06 31/08/06 31/08/06 30/10/06 30/09/06 30/10/06 15. OP19 12 All items of low-level glazing must be suitably marked to identify the potential hazard for people with visual impairments. Remains outstanding from last inspection. 30/09/06 16 17 OP26 OP27 13 18 (1) a The source of odours should be 30/08/06 investigated to eliminate them. The home must ensure that at all 30/08/06 times suitably qualified competent and experienced persons are working at the home in such numbers as are appropriate for the health and DS0000063032.V304611.R01.S.doc Version 5.2 Page 26 Mowbray Nursing Home 18 19 20 OP26 OP28 OP29 18 (1) a 18 (1) a 18 (1) a welfare of residents. The home should review the cleaning cover over the weekends. The home must ensure they have 50 of care staff with NVQ level 2. The home must ensure that they adhere to their recruitment policy. Including obtaining two written references, a full employment history is provided and any gaps explained. Evidence of previous qualifications are provided. 30/08/06 31/12/06 31/07/06 Remains outstanding from previous inspection 21 OP30 18 (1) a The home must ensure all staff receive mandatory training and are updated annually. The home must also ensure that a member of staff is trained in first aid available on duty for the 24-hour period. The registered manager must conduct the care home so far as it may affect the health or welfare of the residents. This should be done through auditing the systems in place. The home makes progress with the requirements identified by the CSCI inspection The home must ensure that the staff supervision program is extended for all staff employed at the home. This should cover all aspects of practise, philosophy of care and career development needs. The extractor fans must be in working order to assist ventilation and avoid potential odours permeating. DS0000063032.V304611.R01.S.doc 30/10/06 Remains outstanding from previous inspection 22 OP32 21 (1) 30/10/06 23 24. OP33 OP36 10 (1) 18 30/10/06 31/12/06 Remains outstanding from previous inspection. 25. OP25 13 30/09/06 Remains outstanding from previous Mowbray Nursing Home Version 5.2 Page 27 inspection 26 OP38 13 The legionella risk assessment recommendation must be followed. The registered provider must address the outstanding health and safety issues, and provide an action plan giving timescales as to when this shall be addressed. • The lift, servicing reports from January 2006 highlighted work to be undertaken. • The five-year installation report from March 2006, some remaining work to completed. • The gas safety certificate requirements had not been actioned. • Recommendations from the legionella had not been followed. • A hoist requiring attention following servicing to the leg adjuster had not been fixed. • The Environmental Health officer’s requirements from their visit in May 2006 had not been addressed. 30/09/06 27. OP38 13 16/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 28 Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Mowbray Nursing Home DS0000063032.V304611.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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