Inspection on 09/02/06 for Mowbray Nursing Home

This inspection was carried out on 9th February 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 19/07/06

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 9th February 2006 12:00 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.V282828.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 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 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.V282828.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 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. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of six hours and was undertaken by two regulation inspectors from the Worcester office of the Commission for Social Care Inspection (CSCI). The last inspection at Mowbray took place during September 2005. The Inspection started at 15.00hrs. On the day of the inspection there were 38 residents at the home. The main focus of this inspection was to review requirements from the previous inspection. A partial tour of the home took place and a selection of care, personnel and health and safety records were examined. Staff and residents were spoken to during the visit, in order to ascertain their views on living and working at Mowbray. As a result of the inspection issues of serious concern were identified in respect of medication and fire records. An immediate requirement notice was issued for the home to address. Failure for the home to comply with the immediate requirement notice may result in the Commission for Social Care Inspection taking enforcement action. The owners have responded to the immediate requirement notice and provided the Commission with an action plan of how the requirements would be addressed. This shall be monitored by the CSCI to ensure compliance. What the service does well: Some of the bedrooms have been personalised by the residents, and this helps to give a more homely appearance. The residents confirmed that the home provided a good choice of food and the meals were good. Social activities have improved and the activities co ordinator is enthusiastic about her role. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 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 appropriate care to be provided. EVIDENCE: All residents are assessed prior to their admission to the home to establish their individual needs and to determine if those needs could be met by the home. Residents spoken to stated that the home was meeting their needs appropriately and they were pleased with the service provision. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 Care plans were sufficient, and provided the staff with information regarding residents’ care needs. Risk assessments needed to be undertaken as soon as possible following admission and further development was required to the moving and handling assessment. The management, recording and administration of medication must be improved to ensure that residents are not placed at risk. EVIDENCE: Care plans for six residents were reviewed during the inspection, these evidenced that the registered nurses had improved the records since the last visit. Some further information is required to fully reflect the resident’s need fully. The moving and handling risk assessment was basic and it was recommended a more detailed risk assessment is developed. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 10 Appropriate risk assessments must be completed for the resident on admission to the home. Residents at risk of pressure damage to their skin should be assessed and appropriate intervention implemented. Serious concerns were raised in respect of the management of medication and an immediate requirement notice was issued for the home to address. The medication trolley which was stored on the first floor was observed with an item of residents medication left on the top of the trolley. Gaps were evident on the medication administration record (MAR), with no code recorded whether or not the medication had been administered. Creams and eye drops were in use with no date of opening recorded on them. A full audit of the medication could not be audited given the home was not recording the amount of medication received into the home. Where handwritten alterations had been made to the MAR, the entries had not been countersigned by a second nurse. The temperature of the drug fridge was variable. This should be repaired and or replaced to ensure medication is stored at a safe temperature. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 15 The dietary needs of residents are appropriately catered for. Residents are encouraged to make choices about what they wish to eat and where they wish to eat it. EVIDENCE: Several residents were enjoying visits from family and friends at the time of the inspection. Residents can receive visitors at any time of the day. Visitors confirmed they were able to visit at any time of the day and were welcomed into the home by the staff. The activities co ordinator has started holding regular meetings with relatives and residents. These allow relatives the opportunity to express their views and opinions about the home. Residents, who were asked, stated that the food and choices available were good. The home displays the menu of the day on the board for residents and visitors to see. The catering staff caters to the individuals dietary preferences. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 12 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 home has a simple and clear complaints procedure in place. Polices and procedures are in place in relation to adult protection issues which provide direction to staff and aim to ensure residents are safeguarded from abuse. EVIDENCE: Since the last inspection, neither the home nor CSCI have received complaints in respect of the service provision. The home maintains records of any complaint received and the investigation undertaken to address the complaint. The home has regular meetings with family members, and feels this has helped to address any issues that may occur. Written policies and procedures are in place in order to ensure the protection of residents, which includes a whistle blowing policy. Some staff have received training on types of abuse, full details of the course content were not stated. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 13 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): 19,20,25 and 26 There has been some progress since the last inspection to improve the standard of the environment. Further refurbishment and improvements are now necessary to ensure residents have a clean and safe place to live in. EVIDENCE: The inspectors were advised that the home has been improved in some areas. The general appearance of some areas of the home is tired and fatigued, and would benefit from a redecoration program. The home should prioritise on the areas in most need of redecoration. Many bedrooms have been personalised by the resident, reflecting their personnel choice and presenting a more homely environment . Some carpets were observed to be badly stained on the day of the inspection and would benefit from a deep cleaning program. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 14 Some areas of the home were quite cool at the time of the visit it is recommended that the home monitor the temperature in all areas to maintain a comfortable environment for the residents. Toiletries were observed in one bathroom not identified to a specific resident. To avoid the potential risk of cross infection, toiletries should be stored in resident’s bedrooms. The home is in the process of providing a sluicing disinfector for the first floor sluice; this remains outstanding from the last inspection. It is recommended that the review of the bathing and toilet facilities on the ground floor be undertaken. At the time of the visit extractor fans were not working in the sluices to reduce the potential for odours permeating around the home these should be in working order. Generally the home was clean and tidy and no offensive odours were evident at the time of the visit. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 15 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): 27,29 and 30 Staffing levels per shift appeared appropriate for the number of residents in the home. Procedures for the recruitment of staff are not being adhered to fully, to ensure the protection of residents. EVIDENCE: The duty rota indicated that the number of staff on each shift was appropriate for the number of residents in the home. The home operate with 3 registered nurses plus 6 care assistants on the early shift, 2 registered nurses and 5 care assistants on the late shift and 1 registered nurse with 3 care assistants on night duty. The home use some agency staff to maintain the staffing levels. In addition the home provides domestic, catering, maintenance and administration staff. Four staff files were examined at inspection, these evidenced that the home was not following its recruitment policy fully. Some files showed no evidence of training. The home must ensure all staff receive appropriate training to further safeguard the residents. The records evidenced that not all staff had received fire-handling training. Moving and handling training had not been updated for Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 16 all staff. It is recommended that the home develop a staff training analysis to clearly evident who has received what training and when they are next due. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,36 and 38 The manager is competent to provide effective leadership and appropriate guidance to staff The management of health and safety must improve to safeguard both residents and staff EVIDENCE: Since the last inspection the manager has been approved by the CSCI to be the registered manager for Mowbray. Staff confirmed they found the manager to be approachable and provide effective leadership. Staff commented that the atmosphere in the home was changing for the better, and they felt care practices had also improved. The home must formalise their staff supervision program for all staff working at the home, this should incorporate the staff’s training needs analysis. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 18 Various health and safety issues were raised at the time of the visit. The home must be able to provide evidence that the portable hoists have been serviced, this should be done twice a year. A copy of the legionella risk assessment was not available at the time of the inspection, and clarification is required that the assessment has been undertaken. The gas safety certificate required some improvement work to be undertaken, clarification is required that the work has been completed. An immediate requirement notice was issued in respect of the fire tests; the fire test records were not in sequential order and highlighted four points that cannot be tested, as no key was available. The fire extinguisher visual checks were not being completed monthly. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 2 X 1 Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP9 Regulation 13.2 13.2 Requirement Staff must document the amount of medication administered e.g. one or two tablets Registered nurses must sign each MAR after medication has been administered to a resident. When prescribed medication is not administered to a resident, the reason for nonadministration must be recorded onto the MAR. The quantity of medication received from any source must be documented and any remaining balance carried over onto a new MAR chart. Medication must be stored securely and not accessible to the residents. Any handwritten entries on the MAR must be countersigned by a second registered nurse. The medication trolley must be secured to a solid wall when not in use. To improve medication audit staff must date the opening of all containers (boxes, bottles, inhalers etc) and also carry over DS0000063032.V282828.R01.S.doc Timescale for action 09/02/06 09/02/06 3 OP9 13.2 09/02/06 4 5 6 7 OP9 OP9 OP9 OP9 13.2 13.2 13.2 13.2 09/02/06 09/02/06 28/02/06 09/02/06 Mowbray Nursing Home Version 5.1 Page 21 8 9 OP7 OP8 12 1 a 12 1 a 10 OP7 12 1 a 11 12 OP26 OP21 13 23 13 14 OP26 OP19 13,16 12 15 16 17 OP36 OP38 OP38 18 23 23 18 OP25 13 19 OP29 18 balances of medicines from previous cycles onto new MAR charts. Care plans must accurately reflect the care needs of each individual resident All risk assessments must be dated and signed by the registered nurse completing the risk assessment. Risks identified through assessment must generate a plan of care. Particular attention must be given to (a) pressure ulcer development risks and (b) risks of sustaining injury through falls. All marked, stained or fatigued carpets must be cleaned, repaired or replaced. Communal baths and toilets located on the ground floor of the home must be reviewed and upgraded in response to the dependency of residents. A sluicing disinfector must be provided on the first floor of the home. All items of low-level glazing must be suitably marked to identify the potential hazard for people with visual impairments. All staff must receive formal supervision in accordance with the specifications of standard 26. Fire extinguishers must be visually checked every month. The weekly fire test must be undertaken every week and an accurate record maintained to evidence the check was completed. The extractor fans must be in working order to assist ventilation and avoid potential odours permeating. The home must adhere to their DS0000063032.V282828.R01.S.doc 31/03/06 09/02/06 09/02/06 31/03/06 30/04/06 30/04/06 30/04/06 31/03/06 09/02/06 09/02/06 30/04/06 09/02/06 Page 22 Mowbray Nursing Home Version 5.1 20 OP30 18 21 OP38 13 22 OP38 13 recruitment procedure fully, to further safeguard residents. All staff must be up to date with mandatory training, and a system should be in place to ensure training is updated as required. The legionella risk assessment must be available and the home must evidence they are following the recommendations. The home must have the servicing records available for the portable hoists in use in the home. 09/02/06 09/02/06 09/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP38 OP19 OP25 Good Practice Recommendations A thermometer should be available in all bathrooms so staff can check the temperature of the water it should be between 37°C - 44°C. The home should produce a program of routine maintenance and renewal of fabric and decoration of the premises. Some areas of the home felt quite cool, thermometers should be provided to monitor that a comfortable temperature is maintained. Mowbray Nursing Home DS0000063032.V282828.R01.S.doc Version 5.1 Page 23 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. 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