Inspection on 05/08/08 for Mowbray Nursing Home

This inspection was carried out on 5th August 2008.

CSCI found this care home to be providing an Good service.

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

Mowbray Nursing Home 21/09/09

Mowbray Nursing Home 07/02/08

Mowbray Nursing Home 06/06/07

Mowbray Nursing Home 25/01/07

Mowbray Nursing Home 19/07/06

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Mowbray Nursing Home Victoria Road Malvern Worcestershire WR14 2TF Lead Inspector Chris Potter Key Unannounced Inspection 11:30 5th August 2008 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.V369104.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.V369104.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 01684 891233 julie_askew12@hotmail.com Minster Care Management Limited Kay Lowry (proposed) 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.V369104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2008 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. Minster Care Management Limited owns the home. The Home recently appointed a manager who has many years experience in nursing and management. 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. Information regarding the home is available in the Statement of Purpose, the Service User’s Guide and inspection reports. These documents are available on request from the home. The fees for this home are not published in the Statement of Purpose. For accurate information regarding the fees please contact the home direct. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We, the commission undertook an unannounced inspection of this service over one day by one Inspector. This was a key inspection – this is an inspection where we look at a wide range of areas. Before the inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the service for completion. The AQAA is a self-assessment and a dataset that each registered provider has to complete each year and send to us within agreed timescales. The document tells us about how providers of services are meeting outcomes for people who use the service and is an opportunity for them to share with us what aspects of the service they believe they are doing well. Some of the provider’s comments have been included within this inspection report. During the visit to the home care records, staff records and other records and documents were inspected. Surveys were sent out and received from residents (two), staff (nil). There was a tour of parts of the accommodation and interviews with staff, including the recently appointed manager, and a company representative. Time was spent speaking privately with residents in their rooms as well as spending time out and about in the home observing what was happening and talking to residents and their relatives. Since the last key inspection the home’s respite unit has closed, and the six beds are now included within the homes registered beds. We have received one complaint about the service since the last Key Inspection was completed in February 2008 this is explained in the complaints section of the report. What the service does well: Staff address and care for residents’ in a sensitive manner, which ensures their privacy and dignity, is maintained. Residents receive a good quality varied diet and residents are consulted regarding food preferences and choice of menu. They have a good choice of a cooked breakfast, cereals, porridge, toast and bread and butter with fruit juice, tea and coffee to drink. Residents are able to eat in the dining room or in the privacy of their bedroom. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 6 The home has a complaints procedure, which is available at the entrance to the home. Records of complaints and their investigation and outcome are held in the home. A suggestions box is also available. The manager visits prospective residents and completes an assessment of their care needs to ensure they are able to provide the care needed. The home’s management of medication is well organised, and the manager completes audits to monitor that the nurses’ are administering the residents’ medication correctly. What has improved since the last inspection? Following the last key inspection in February 2008, which rated the service poor, the providers have invested additional resources into the home to improve the service provision for people using the home. We monitored the home through random inspections’ and liaising with other health care professionals who were randomly visiting the home. We are pleased with the progress made by the home since February 2008. This is reflected by the number of requirements’ addressed since the inspection. An experienced manager has been appointed and told us how she is addressing the shortfalls, which were highlighted at the last key inspection in February 2008. From looking at the residents care records there has been significant improvement made. The manager showed us the audit system introduced to assist the management monitor that this improvement is continued. Staff told us that the staffing levels have improved, and more nurses’ have been recruited to replace the ones who recently left. Staff also told us that the atmosphere in the home has improved providing improved communication, and that they felt more supported with the appointment of the new manager. The care needs assessment, which is completed; to ensure that the home can meet the prospective persons’ care needs has been improved. A completed assessment looked at showed that this provides the staff with sufficient information to provide the care to meet those assessed needs. The organisation of staff training has improved and all staff are provided with an intensive induction-training package to assist them in meeting the care needs of people using the service. The member of staff responsible for new staff induction showed us the contents of the training package and advised us how staff are benefiting from the training. Residents and staff, told us that the quality and choice of food had improved from the last inspection, they were offered a choice of cooked breakfast every day of the week, choice of cereals, toast and marmalade, prunes and fruit Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 7 juices. The home offers a choice including vegetarian option for lunch or a choice from the daily alternatives, and for tea a choice of hot or cold food is available. The complaints records have improved, and a suggestion box as been placed in the entrance area of the home to assist with monitoring peoples’ views about the home and the services provided. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mowbray Nursing Home DS0000063032.V369104.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.V369104.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2 and 3, standard 6 is no longer applicable to this home. Quality in this outcome area is adequate. Residents are confident that the care home can support them. This is because there is an accurate assessment of their needs that they have been involved in. This tells the home all about them and the support they need. Residents who stay in the home know about their rights and responsibilities because there is a contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This judgement has been made using available evidence including a visit to this service. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 10 EVIDENCE: We saw copies of the home’s statement of purpose and service user guide in the reception area of the home and a copy of the service user guide was seen in residents’ bedrooms. A copy of the service user guide was reviewed and updated with the changes made since the last key inspection including the new manager’s details. It is recommended that the service review alternative format for their service user guide to assist people with sensory impairments. Following the last key inspection the home was given a poor rating and because of the concerns was referred under multi agency “safeguarding” procedures. This is a procedure whereby health and social workers review the people using the service to ensure that their health and welfare is protected. The provider co-operated with the authorities and placed a voluntary ban on new admissions into the home until some of the issues had been resolved. The service provided an improvement plan that showed how they were actioning the requirements from the key inspection. The service was monitored by us and the other authorities to review progress with the improvement plan. The intermediate unit closed in March 2008,and the six beds have been included within the homes total registration. We looked at two people’s pre-admission assessments’ that had been completed prior to the person moving into Mowbray. The manager told us she has developed a more thorough pre - needs assessment. This was a requirement at the last key inspection. The assessment assists in determining that they are able to meet the health and personal care needs of the individual. The assessments’ were clear and contained sufficient information for the home to develop a plan of care based on the initial assessment. The assessment showed that the person and their relatives had contributed and agreed to the contents. Surveys received prior to the inspection confirmed that they had been assessed, prior to moving into the home, and provided with sufficient information to assist them with their choice. We saw copies of the contracts between the home and the resident; the administrator is responsible for reviewing these. The Annual Quality Assurance Assessment completed by the manager indicates that the home could improve their lines of communication so that all staff have as much information as they need to equip them to provide a high standard of care to our residents. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8,9 and 10 Quality in this outcome area is Good. The people’s health and personal care needs are met. The home has a plan of care that where possible the person or someone close to them has been involved in making. The home supports people with their medication in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The provider advised us in their improvement plan that all the care plans had been reviewed and updated. We evidenced this progress through our random inspection visits to the home. Since the last key inspection all residents care records have been re-written and updated. Three residents’ care records looked at showed that the care records had been agreed with the person or if appropriate their relative. The record provided clear information of why the Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 12 person was being cared for in a nursing home, and how the home, were meeting the health, welfare and psychological needs of that person. Risk assessments had been completed and were being used to assist in monitoring the individual’s health and to identify any changes that may need additional resources. For example, the manager told us that ten people were having weekly weight monitoring from the nutritional risk assessment undertaken. The nurses are recording meaningful daily statements about the person and the care provision. The manager told us that the care records still required some additional information and that she would be monitoring the progress through monthly audits. The deputy manager advised us that the tissue viability nurse had completed an audit of the home’s pressure relieving equipment. In response to the audit a number of new beds and mattresses, including four specialist beds for the more dependant residents’. A Resident’s care book is held in each resident’s bedroom. The book contains information about the individual’s preferences for example times for going to bed in the evening and getting up in the morning. Also included are the person’s preference in activities, dietary likes and dislikes. The activity organisers’ are also completing a personal calendar of planned activities so relatives can plan their visits around the timetable. Residents told us that staff are respecting their wishes an example being times of getting up in the morning. We were told by staff of all grades that the atmosphere in the home had improved and they were working together as a team. Staff stated that the resident’s care needs were being met, and the staffing levels were sufficient to be able to do this. Comments from residents and relatives were positive about the care and the staff. All the staff spoken with demonstrated a good knowledge and understanding of the residents care needs. Comments included: “staff are helpful” “always appear to be enough staff on duty” “no complaints with the home” “everything is done when asked” “staff are slow sometimes in answering the call bells” “would appreciate a more modern hoist to assist with moving the residents ours is quite old” We received positive feedback from other healthcare professionals, who feel that the service has moved forward, and addressed the issues from the Key inspection. We looked at how medication was being managed for the three people we were case tracking and found the system to be well organised. A copy of the original prescription was available to check that the details on the medication administration record were correct. A record was seen of all medication received into the home. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 13 We saw that all the new staff had provided a copy of their signature so that the manager when auditing the system can clearly identify who had completed the medication on each shift. We saw that the homely remedies policy had been signed and agreed by the visiting GPs. This allows the nurses’ to administer medication that has been purchased over the counter for up to 24 hours and then if needed a prescription could be provided. The medication administration records seen were well documented with no gaps on the record. The balance of medication was correct for those residents checked. We observed staff respecting the residents’ privacy and dignity. For example knocking on doors before entering private rooms and speaking to them courteously. Male and female care staff are employed so residents are able to receive personal care from someone of the same gender if they wish. The Annual Quality Assurance Assessment completed by the manager indicates that they are working to further improve the care plans, to make them more person-centred and will continue to expand upon the improvements already made. To provide on going training courses, continue to offer meetings with residents and their families. To improve lines of communication so that staff have all the information they need to ensure residents receive a high standard of care. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The provision of social and recreational activities for residents has improved, and are person centred depending on the person’s needs. People are able to keep in touch with family, friends and representatives. They are as independent as can be. People have nutritious meals and snacks, at a time and place to suit them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs two part time activity organisers who cover 46 hours over the week including, some evenings and weekends. They develop a planned weekly calendar of social events for the individual based on their choice and capabilities. Residents’ told us that their wishes are respected, if they chose not to participate this is respected. Some residents advised us that they prefer to stay in their bedroom’s including for meals and confirmed this is respected. We were shown a copy of the monthly leaflet produced by the activity organiser for the residents. This provides quizzes, information about forthcoming events and gives prizes for the winners. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 15 Staff told us that the activities were suited for the residents’ dependant on their needs. Two staff felt that the home was not meeting the religious needs of all the residents. The home currently provide a monthly church service with options for a one to one service for those unwilling or unable to go to the lounge. Comments we received from residents and staff included: “The activities are fairly good”. “going out, picnics, belly dancing” “Activities include going out to pubs, garden centres and visiting art/craft sales.” The manager told us of the changes around meal times to make more of an effort in encouraging residents who are able to go to the tables in the dinning room. She has introduced protected meal times so all staff can assist with the meal and assist the residents who require assistance. Relatives have been asked to respect the meal times and not visit if possible. We were told by residents and staff that the quality and choice of food was good. The chef confirmed that the menus have been reviewed since the last inspection, offering the residents a more varied choice; menus are displayed in the entrance to the home. The menus rotate on a four-week rotation. Breakfasts- the home offers a full cooked breakfast seven days per week, or cereals, porridge, toast, fruit juices etc. Dinner – the home offers a hot main course including a vegetarian option or the residents can have a choice of salad, jacket potatoes, omelettes, cheese and biscuits. Tea – The home offers soup, sandwiches or a hot dish i.e. tuna bake, cauliflower cheese. The menu seen was varied the residents are offered a choice the day before. The homes permanent chef is currently off sick, so the part time chef is covering full time. The administrator told us that they use all local suppliers for food and are able to trace where all food came from. They received a four star rating from the Environmental Health Officer’s most recent inspection in June 2008. Comments about the food included: “food always looks nice” “food is good” The lunch being served at the time of the inspection looked appetising, and the soft diets were attractively presented. Residents’ were being assisted by staff respectfully. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 16 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): Standard 16 and 18 Quality in this outcome area is good People who use the service are able to express their concerns and have access to the homes complaints procedure. Mowbray safeguards people who use the service from abuse and neglect, and takes action to follow up any allegations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We received one complaint since the last key inspection in February 2008. During the investigation it was evidenced the complaint was in response to media correspondence and the issues had already been addressed by the home. The home’s complaints procedure and records were seen; a copy of the homes complaints procedure was seen in all bedrooms. The manager has also introduced a suggestion box in the entrance to the home. Residents and relatives spoken with were aware of the homes policy and who to report concerns to. Records showed that six complaints had been received by the home since the last inspection in February 2008. These related to a cold cup of tea, state of a resident’s bedroom when visiting, a relative given conflicting information, an allegation about a nurse, the other two were in response to the concerns raised at the key inspection which had been addressed. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 17 The Annual Quality Assurance Assessment states that new forms have been introduced to record verbal complaints. Aim to improve the time taken to respond to complaints. The home was referred to the lead agency for safeguarding adults following the concerns raised by other agencies that commission care from the home. This is now closed and the authorities are pleased with the homes progress. We were told by staff that they had received Safeguarding training and were aware of the homes whistle blowing policy. Staff also confirmed that they would have no hesitation in reporting any concerns to the manager. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 and 26 Quality in this outcome area is adequate Minor improvements have been made to the décor of the home and some equipment has been purchased to provide a more homely and comfortable environment. Some further improvement is needed to ensure all areas of the home are pleasant, homely and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is converted from a large period Victorian house, which stands in a convenient location in Malvern with pleasant grounds. The design and layout of the home does not enable staff to use specialist equipment in all areas. The corridors in parts are narrow, steps leading to some bedrooms. The home possesses poor lighting levels. People using the home are risk assessed for suitability to these areas. The home would benefit from reviewing they’re Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 19 bathing facilities to assist residents with complex needs and offering the choice of a bath or shower. Staff commented, “The downstairs shower is brilliant” The company representative told us that they have invested in the home and have replaced floor coverings in the kitchen and three bedrooms. The storeroom for food storage has been upgraded. New beds, bed linen and additional pressure relieving equipment has been purchased. From observation the home generally appeared less cluttered and no odours were evident from walking around the home. Some bedrooms are personalised and the residents spoken with said they were pleased with their bedroom. Upgrading all of the decoration and securing new furniture and carpets could further enhance the appearance of the home. The furniture and carpets in many areas of the home presents as being tired and worn. The manager told us that the providers are planning to upgrade the home when work has been completed in one of their other care homes. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate There is enough staff to provide the people who live at the home with the appropriate support needed by staff that get the relevant training and support from their manager. The procedures for recruitment of staff are robust and offer further protection to the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the home’s duty rotas, which confirmed that the home is providing sufficient staff proportionate to the number of residents and their care needs. Residents, relatives and staff told us that there was enough staff available. Staff stated that the only exception to this was when staff went off sick at short notice. We observed staff responding promptly when the nurse call bells were activated. Staff comments included: “Normally on days there are three members of staff downstairs and two members upstairs plus the trained staff. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 21 In the evening there are three members of staff downstairs and two members upstairs plus the trained nurse. On nights we have three carers plus a nurse” “we only do laundry when no one is available which is not very often”. “we have a series of training which includes moving and handling, fire, infection control, health and safety and dementia”. “Training includes health and safety, food and hygiene, moving and handling” “I feel the training is appropriate to meet the needs of the residents”. “The atmosphere is better we are working as team” “the manager and nurses’ are supportive”. The home has appointed a senior carer to oversee the induction training of all new staff. She shared the training records with us, which showed a comprehensive training package in relevant areas. We were told by the manager that she is looking into NVQ training qualifications for the care staff to complete. The home employs male and female staff from a multi – cultural background, and respect the preferences of the people using the service for male or female staff. Comments received from relatives included; “compliments to all staff with grateful thanks for all the care”, and “Staff are excellent, food is excellent”. The Annual Quality Assurance Assessment stated, “ the home is providing regular training sessions for staff. The staffing levels have improved resulting in less use of agency staff. A supervision program as been started with a planner to monitor the frequency of staff supervision. We are looking to promote NVQ training. We have instigated an active recruitment programme and seek to provide replacements in readiness for maternity leave etc”. We looked at the personnel record files belonging to two staff members and records showed that the home had carried out all the appropriate security checks before the staff had started working at the home. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,36 and 38. Quality in this outcome area is good. With the appointment of the new manager, people have the confidence that with the open approach that the home is being managed appropriately. The environment is safe for people and staff because appropriate health and safety practises are carried out. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager told us she had started working at the home the first week of June 2008, and that she is in the process of registering with us. She is a registered nurse with experience of managing a nursing home. She told us about the various training courses she has attended to maintain her nursing Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 23 competencies and skills. She advised that there was a good atmosphere and staff and residents had made her feel most welcome. We were told by staff that the manager had made a good start to the home and was supportive and approachable. We observed the manager interacting well with the residents, staff and visitors to the home. We looked at the staff supervision records dated June 8th 2008. The manager has completed a supervision plan, which shows when supervision is due. The comments in the supervision records were constructive, and the manager was addressing the staff’s comments. The provider should consider Internet access for the home, as this provides easy access to information and could assist with staff recruitment and training and with the validation of nurses’ registrations. The company representative is completing monthly visits to the home and provided us with copies of these visits at the inspection. These visits are a requirement of the Care Standards Act 2000, and assist the provider in monitoring their compliance with the National Minimal Standards. We were told by the administrator that they do not hold any money for the residents. All financial transactions are receipted for payment from the residents’ relatives, or advocate where applicable therefore key standard number 35 has not been inspected. We were shown all the maintenance and servicing records by the administrator for systems and equipment. These were well organised and up to date. The administrator has a good system in place for monitoring when checks are due for renewal. The Annual Quality Assurance Assessment submitted provides a good picture of the service and the plans for further improvement over the next twelve months. Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 24 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 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A 2 X 3 Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP1 OP19 Good Practice Recommendations To assist people using the service the home should review producing their service user’s guide in a format to assist people with sensory impairments. To assist people using the service the home should continue the decoration of the home and replace furniture and furnishings where needed. This is to ensure that people live in a comfortable and pleasant environment. The service must ensure that at least 50 of care staff has a NVQ Level 2 in care or equivalent. This is to ensure that people can have their needs met by a staff group that is adequately skilled. To ensure that people living in the care home are further protected then service should look at internet access. This will assist staff in referencing clinical sites for guidance and information on best practises, medication and information to assist with recruitment. 3. OP28 4. OP38 Mowbray Nursing Home DS0000063032.V369104.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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