Inspection on 06/06/07 for Mowbray Nursing Home

This inspection was carried out on 6th June 2007.

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mowbray Nursing Home Victoria Road Malvern Worcestershire WR14 2TF Lead Inspector Chris Potter Key Unannounced Inspection 6th June 2007 09:15 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.V336523.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.V336523.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 K Sanders (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.V336523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2007 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 proposed manager for the home is Mrs K Sanders who is a 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 are between £530.00 and £600.00 per week depending 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.V336523.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes key unannounced inspection and was carried out over two days by three inspectors from the Commission for Social Care Inspection, one a pharmacy inspector. The total time of inspectors’ time at the home was 22 hours. The inspection focused on the outcome for the residents. Given the requirements from the last inspection the home had been required to provide the CSCI with an action plan providing timescales as to when the requirements would be addressed. This inspection found significant improvements in some areas. Prior to the visit the manager had completed an Annual Quality Assurance Assessment(AQAA), and returned it to the CSCI. No comment cards were received from residents’ relatives’ or other professionals prior to the inspection. A tour of the home was completed; a sample of care records, staff records, maintenance records, discussion with some residents and staff was completed on the first day of the inspection. The second day focused on the homes management of medication. The reason for this inspection was for a pharmacist inspector to carry out a specialist inspection of the arrangements for handling medication (National Minimum Standard 9 Care Homes for Older People) as part of the key inspection. This included looking at some stocks and storage arrangements for medicines, some medicine record charts, some other medication records, the medicine policy and procedures. There were discussions with three nurses who were on duty, the Area Manager and Business Manager. Two people who live in the home were spoken with in their rooms. The proposed manager and area manager were present throughout the inspection. The inspectors would like to thank them for their time and assistance throughout the inspection. What the service does well: Mowbray has a core of stable and committed staff, and this is evident from the number of years many staff have worked at the home. There is a pleasant atmosphere in the home and all staff were observed to be interacting well with the residents during the inspection. Mowbray has a robust recruitment procedure and is committed to staff training. The grounds are very well maintained providing pleasant views from the home. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 7 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.V336523.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.V336523.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): 1,3,4 and 6 Quality in this outcome area is adequate. The Service Users guide and Statement of Purpose provides sufficient information about the facilities on offer and the philosophy of care. The pre – admission assessment provides adequate detail too ensure that the home can meet the assessed needs of prospective residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has updated their Statement of Purpose and Service User’s Guide. A copy of the Service User’s Guide was available in all the residents’ bedrooms. Two residents spoken with during the inspection who had recently been admitted confirmed that they had been provided with the Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 10 appropriate information to assist them in choosing the home. They both confirmed that they were pleased with their rooms and found the staff to be pleasant and helpful. Four residents care files were reviewed for people who had been recently admitted to the home. These contained a copy of the pre - admission assessment that had been completed by the proposed manager and area manager prior to their admission to the home. Residents spoken with confirmed that they had been seen prior to being admitted to the home. The rehabilitation unit was looking after five residents on the days of the inspection. One member of staff was looking after the residents on the unit. There has been lots of discussion about the respite unit and the last two inspections reported that the home is not meeting its contractual agreement with staffing the unit. The contract is for two staff to work on the unit, however it remains with only one nominated member of staff. The member of staff reassured inspectors that when help was needed it was provided from a carer in the main home. The outcome for the service users on the unit was positive and they were complimentary about their stay. Mowbray Nursing Home DS0000063032.V336523.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): 7,8,9,10 and 11 Quality in this outcome area is adequate. Care plans generally contained sufficient information about the residents care needs, and how care is to be delivered by the nurses and care staff. Where potential risks are identified a care plan should be developed to minimise that risk. People who live in this home are generally protected by the home’s policy and procedures for dealing with medication but the report identifies some issues for attention to make sure of their health and wellbeing. Staff ensure that the resident’s dignity and privacy is respected at all times. This judgement has been made using available evidence including a visit to this service. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 12 EVIDENCE: Some significant improvements were evident with the quality of information available in the residents care plans from the previous inspection. The responsibility for this is down to the manager and area manager’s efforts. It was disappointing to find that care records when the manager was off lacked information and failed to provide clear guidance on how the care needs of the residents would be achieved. The home should remind all registered nurses about their professional accountability and the necessity of maintaining accurate records. Generally the majority care plans were reflective of the residents care needs and provided guidance for the care staff. Identified risks had been developed into the care plan and guidance on how to minimise the identified risk was stated. One care plan for a resident who had been admitted the day before the inspection failed to record the identified care needs of the resident. Whilst appreciating a full care plan takes time to fully complete, a basic care plan based on the residents pre-admission needs, and information provided from the resident if they are able to assist. The care plan should be continually reviewed to reflect any changes in the residents care needs. Another residents care plan failed to clearly evidence the deterioration in a resident’s condition and increasing dependency. It also failed to develop a care plan for an entry in the daily records to a break in skin. Any change to the residents care needs should be recorded and risk assessment reviewed. In the homes AQAA they are aware of the need to further develop care plans they stated, “ To improve our care plans and documentations so that all the information is accessible to those who need it”. “ To include the resident and their families more in the involvement of the care plans.” All staff spoken with during the inspection were fully aware of the residents care needs. Comments from the residents included: “All staff are relaxed and helpful”. “All staff are pleasant and helpful”. “Communication is difficult with foreign staff. The home has a medicine policy and procedures together with a homely remedies protocol so that staff are aware of how the home expects medicines to be managed. A nurse who had recently started working in the home was aware of the policy and said she was shown this on starting. The policy may need reviewing to update the section on the disposal of medicines and include specific local issues. The medicine reference book was published March 2006 and needs updating to the latest edition (March 2007) so that staff have up to date information about the medicines they are using. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 13 There are records of medicines received, administered and disposed of to make sure there is no mishandling. There are audit-checking systems in place. A local pharmacy provides most medicines each month in a monitored dose system with printed medicine charts on which staff record the medicines administered. Most charts looked at had been completed satisfactorily with explanations for any medicines not given. Handwritten entries were double signed as checked. Issues noted for attention are: Always record the actual dose given when the directions allows a variable dose (10 to 15ml for example) to allow proper monitoring of treatment. There is a procedure for nurses to record medicine dose changes given verbally. For medicines such as anticoagulants the dose should be confirmed in writing to make sure there are no mistakes. Using the standard anticoagulant treatment book is best practice. Proper records are not made for some skin treatments applied particularly those carried out by carers. Medicine chart files are kept on top of the trolleys, which are in public areas, so does not respect their confidentiality. Some people are prescribed medicines to use ‘as required’ but there is little in the records to say what this means. Protocols are needed to clearly describe to staff exactly how to use such medication so that it is used consistently for the benefit of that person. Some people are able to say if they need the medicine and staff did ask when they were administering medicines. This sort of information can be included in a protocol. Medicines are administered to people living in the home by registered nurses. The medicine round printed on the charts as 8am was completed at 11.30am so there is a concern that people having lunch doses as well may not have the correct time interval between doses or be given their medicines correctly in relation to food. Staff said they begin the 8am medicines at 9am so the times printed on the medicine charts need changing to more closely show the times medicines are given. There are three medicine trolleys in the home to help with adopting safe practices for administering medicines. It is not safe to walk around the home for some distance with medicines in a small cup as this can lead to mistakes. The procedures must be reviewed to make sure safe practices are always followed. Medicines must only be used for the person named on the container label. Sharing of containers was found for a particular medicine. Two people living in the home were spoken to about their medicines. Both confirmed that staff always give them their medicines and were very complimentary about the staff. One person who had come to the home recently said that staff automatically took the medicines from her but she was happy with that. Care plans should reflect what choices people are given and have made about their medicines. Nobody at the time of the inspection was looking after and taking medicines themselves. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 14 Some audit counts of medicines in stock were carried out. Most were correct indicating that medicines are given as recorded. Some tablets had been out of stock for three days for one person, which could adversely affect their health. During the inspection staff confirmed the tablets were on order for delivery that afternoon. We confirmed that this in fact happened and a dose was given that evening. A note in the records for another person indicated that two tablets had been given the previous day instead of one. For another person there was some doubt in the records if a tablet due at 2200 on 1/6/07 had been given although signed for before this time. The audit count could not confirm this either. Medicines are stored safely. Most containers have opening dates written on the labels, which is good practice to make sure stock is rotated properly and helps with audit checks. Some creams are kept in bedrooms but did not have an opening date written on the container. This should be done so that they can be replaced after recommended periods in use and so reduce risks from contamination. Storage arrangements in rooms must be checked to make sure there is no risk to anyone living in the home. Storage for controlled drugs needs upgrading to comply with The Misuse of Drugs (Safe Custody) Regulations 1973. There is a signed daily check in the record book of all controlled drugs. The record book and stock agreed and sample checks with medicine charts were in agreement with one exception where a dose was recorded in the book but not on the medicine chart on 26/05/07. Medicines for disposal are returned to the pharmacy but the manager must check that these arrangements are in accordance with the Special Waste Regulations 1996. Where staff use lancing devices to take blood glucose measurements from people living in the home these devices must be safe for using in a care home setting in accordance with published Medical Device Alerts (MDA/2006/066 from www.mhra.gov.uk). Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 15 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 and 15 Quality in this outcome area is good. The independence of residents is encouraged. Activities for some residents have improved since the last inspection. The dietary needs of the residents are well catered for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs an activities co-ordinator who develops activities based on the individual’s wishes and capabilities. One resident advised the inspector how they preferred to stay in their room and listen to the radio, but likes to sit in the gardens when the weather permits. The home accesses transport three days per week to allow individual residents who area able to go out. Religious services are provided in the home. The home maintains records of social activities. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 16 Relatives and visitors are welcome to visit the home at any time. No relatives were present during the times of the inspection. Residents being case tracked confirmed that the home respected the times they wished to get up and go back to bed. The residents confirmed that the staff respected their privacy and dignity. Generally the comments about the food was good, and that they were provided with a choice. One resident commented that the choice for breakfast was poor in contrast another resident stated that the breakfast was excellent and they had enjoyed a full cooked breakfast. Staff spoken with felt that the food was good, one member of staff felt that the home should provide a wider selection of choice with more variety. The catering staff maintain appropriate records, however some gaps were evident in the records. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 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 a robust, effective complaints procedure, and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home complaints procedures are provided to residents and their families on admission to the home. Residents spoken to confirmed that they were aware of how to complain and who to complain to. The home maintains a record of any complaint reported, and details the action taken to address the complaint. One complaint has been received by the CSCI since the last inspection and the home investigated this using their complaints procedure. The AQAA and training records confirmed that staff have received training in protecting vulnerable adults. All staff spoken to confirmed that they had received training and would have no hesitation in reporting poor practice. Mowbray Nursing Home DS0000063032.V336523.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): 19,20,22,23 and 26 Quality in this outcome area is adequate. The home’s appearance would be further improved by more decoration and provision of new furniture and furnishings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is located in a residential area of Malvern. It is a large home providing accommodation for 39 residents. The home has a total of 27 single bedrooms (13 with en - suite facilities) and 6 double bedrooms (5 with en – suite facilities). The home is set back from the road by a well-maintained garden providing a pleasant outlook. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 19 Since the last inspection the home has continued with some minor decoration to some bedrooms. The area manager advised that new bedroom furniture was on order this should assist in improving the appearance of the bedrooms. In many rooms the bedroom furniture was either badly stained or broken. It is also recommended that when upgrading the bedrooms the light shades and chairs be replaced as these were well worn in the majority of bedrooms. Some carpets on the landing area were badly stained. Residents spoken to in their bedrooms stated that they were pleased with their room. Many having personalised their room with pictures and photographs. It was recommended that the home tidy and clean rooms waiting to be cleared by relatives as this could cause them further upset. All windows above ground level have restricted opening, and all radiators have protective guards fitted to further protect the resident’s health and safety. The home has upgraded the shower room on the ground floor, and is reviewing all bathing facilities. Several hoists were observed around the home, staff spoken with felt an additional hoist to assist residents to stand would further benefit the residents. This was discussed with the area manager. The home has had all glazing checked since the last inspection. The maintenance operative checks all the water temperatures and keeps records of the temperature of the hot water. Given the size of the home the management of odours was good. The home employs a member of staff to work in the laundry, staff spoken with stated that they were rarely asked to work in the laundry, more so on nights to help keep the washing down. Mowbray Nursing Home DS0000063032.V336523.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): 27,28,29 and 30 Quality in this outcome area is good. There are sufficient staff on duty at all times to ensure the care needs of the residents are met. The home follows a rigorous recruitment policy to further protect the residents. The home is committed to training to ensure that they understand the care needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty records were examined during the inspection. These showed that the home was providing staffing levels within the minimal recommendation for the 32 residents being accommodated. However from discussion with staff and residents they felt that the numbers were low. The need to ensure that the staffing levels are appropriate for the dependency and the size and layout of the home was discussed. Also the registered nurses felt that they did not have appropriate time to keep up with the amount of paperwork. As mentioned in Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 21 the first section of the report the home is failing to meet their contractual agreement with the number of staff covering the rehabilitation unit. The files of three recently employed staff were reviewed these showed that the home had completed the appropriate checks prior to their commencement. All staff confirmed that the home is committed to training and they felt that they had received appropriate training to assist them with their work. The home now has 5 staff that have completed NVQ level 2 with another 8 undertaking the award. Training courses for staff has improved and staff were positive about the training courses. Staff spoken with are committed to their work and felt it was a pleasant atmosphere to work in. A resident recommended that it would be helpful if all staff wore identity badges to assist the residents in remembering their names. Mowbray Nursing Home DS0000063032.V336523.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): 31,33,35,36 and 38 Quality in this outcome area is adequate. The home is being managed by a qualified nurse who is awaiting registration with CSCI. Since the last inspection there has been little progress with the development of the quality assurance monitoring. All equipment is serviced and maintained to ensure safety and This judgement has been made using available evidence including a visit to this service. Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 23 EVIDENCE: The proposed manager has many years experience in care of the elderly. She is awaiting registration with CSCI. Staff The proposed manager demonstrated good knowledge and understanding of the resident’s care needs. The home has developed a questionnaire for the relatives this should be expanded to monitor the homes systems for. The staff supervision program is well established and staff confirmed that they find the supervision sessions really helpful. Residents’ finances are not managed by the home; they are usually managed by their relative or an advocate on their behalf. The home has service and maintenance contracts for all equipment in the home. The records were available at the home and a copy of the service dates were provided by the home in their AQAA. It was recommended that the home train someone else to test the fire alarms when the operative is away as gaps were evident when he was on holiday. Some issues remain outstanding from the last inspection and the home is requested to notify the CSCI when the outstanding work is completed. Mowbray Nursing Home DS0000063032.V336523.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 X 3 3 X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 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 2 X 2 2 X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement Timescale for action 07/07 2 OP9 13 (2) 3 OP9 13 (2) 4 OP9 13 (2) Medicines must only be administered to the person whose name is on the container label. When medication is administered 07/07 to people living in the home safe procedures must be followed using correct intervals between doses and following labelled directions for giving in relation to food. It must be clearly and accurately recorded and given according to the doctors’ directions. There must be up to date medicine care plans to clearly describe how to use any medicines prescribed to use ‘as required’. This is to make sure that people receive the correct levels of medication. When medicines are disposed of 07/07 this must be in accordance with the Special Waste Regulations 1996. When staff use lancing devices 07/07 to obtain blood glucose samples from people living in the home the device must be safe to use in a care home setting as described DS0000063032.V336523.R01.S.doc Version 5.2 Mowbray Nursing Home Page 26 5 OP9 13 (2) 6 OP6 13 in MDA/2006/066 Upgrade storage arrangements 08/07 for controlled drugs to comply with The Misuse of Drugs (Safe Custody) Regulations 1973. The home must review their 01/09/07 intermediate care unit to ensure that they are meeting their contractual requirements. Remains outstanding. 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 3 4 Refer to Standard OP9 OP9 OP9 OP9 Good Practice Recommendations Provide access to an up to date authoritative medicine reference so that staff have reliable information about medicines they use. Write the date on containers of creams and ointments in bedrooms when they are first opened to use to help with good stock rotation. Make arrangements to have written confirmation of anticoagulant dose changes. Care plans should reflect what choices people who live in the home are given about how their medicines are handled and where appropriate their consent to nurses administering their medicines. 5 OP33 Systems need to be in place review and maintain quality monitoring within the home. It is recommended that all nurses be reminded of their professional accountability with the recording of care plans. It is recommended that the home provide the CSCI with an action plan detailing timescales for upgrade to the decoration and outstanding health and safety issues. It is recommended that the home review their staffing levels accounting for the dependency of the residents and the size and layout of the home. 6 7 8 OP7 OP19 OP28 Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 27 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: 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. Extracts may not be used or reproduced without the express permission of CSCI Mowbray Nursing Home DS0000063032.V336523.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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