Inspection on 15/01/09 for Mulgrave House

This inspection was carried out on 15th January 2009.

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

Mulgrave House 21/11/06

Mulgrave House 15/03/06

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Mulgrave House 9-11 Springfield Street Rothwell Leeds Yorkshire LS26 0BP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sean Cassidy     Date: 1 5 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Mulgrave House 9-11 Springfield Street Rothwell Leeds Yorkshire LS26 0BP 01132821937 01132821654 brownacs@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Camelia Care Limited Name of registered manager (if applicable) Mrs Susan Nyakwangwa Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category terminally ill Additional conditions: Date of last inspection Brief description of the care home Mulgrave House provides personal and nursing care for 36 older people. It was established in 1987 and has been registered under new ownership in September 2005. The original building is of historic interest therefore subject to building restrictions. The building has been extended over the years to incorporate neighbouring cottages and a single storey modern extension. Accommodation is in 23 single rooms, 7 with en suite, and 5 double rooms, 3 of which have en suite facilities. A recent extension to the building has created three additional bedrooms with en suite facilities. There are three areas for communal dining/sitting. The upper floor is accessible by passenger lift. Care Homes for Older People Page 4 of 27 care home 36 Over 65 36 0 0 3 Brief description of the care home The well- stocked gardens provide year round colour and interest. The home is situated close to the centre of Rothwell, midway between Leeds and Wakefield. Local amenities and public transport are easily accessible. The range of fee charged for care is 417.02 to 582.08 Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The accumulated evidence used in this report has included: A review of the information held on the homes file since its last inspection. Information submitted by the registered provider in the Annual Quality Assurance Assessment Surveys received from service users, relatives and staff. An unannounced visit to the home, which lasted eight hours. This included a partial tour of the premises. Care Homes for Older People Page 6 of 27 Evidence gained by direct observation, talking with people who use the service and management. Inspection of records including care plans, risk assessments, medication administration records,and the homes policies and procedures. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 27 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand 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 is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed prior to moving in. They are provided with good information about the service to help them make their choice about moving in. Evidence: Three relatives spoken with said they were offered good opportunities to come and look around the home before their relatives were admitted. They said it was not possible to bring their relative to visit the home because of their healthcare needs. All those people contacted during the inspection said they were provided with enough information to make their choice about taking a place in the home. The care files of the two most recent admissions to the home showed that a preassessment was carried out before they were admitted. This is good practice as it enables the manager to assure herself that the staff at the home have the skills and Care Homes for Older People Page 10 of 27 Evidence: knowledge to meet the care needs of the people who live there. Care Homes for Older People Page 11 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, 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. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the service receive a care package that is developed to meet their needs. People are treated with dignity and respect. Evidence: The care files of three people were inspected. These showed good evidence that peoples care needs are assessed when they arrive at the home. Evidence showed care plans were developed to provide for those identified care needs. Risk assessments in areas such as nutrition, tissue viability, falls and moving and handling were developed and in place. Both care plans and risk assessments showed evidence that these documents were reviewed monthly. This is good practice. Good evidence was available to show other health care professionals reviewed people regularly in the home. Evidence was also in place that showed people are involved with consenting to their care that is planned for them. It was recommended that people dont have to sign every document but could sign a single covering document that states they have read all the information and that they have given their consent. Care Homes for Older People Page 12 of 27 Evidence: The home has a system in place for auditing the care plan documentation, which is good practice. When the audit was inspected I identified that the relative of a lady living at the home was asked for her comments. She identified that the buzzer was too far away from the bed and could not be used and that the table on which she ate her food was too high for her and this posed problems. It is recommended that when changes with care needs are identified staff should ensure the care plans are altered to recognise the change in need. Many examples were seen over the course of the day when staff provided the care needed in a respectful and dignified manner. The home implements a CHESS (Care Homes End of Life Support Services) service that helps promote dignity in the final days of a persons life. This is good practice. However, one resident living in the home said, its like a prison in here. I cant get my cigarettes when I want! This was discussed with the manager and it was recommended that some form of agreement needed to be written down with this individual to ensure his rights were being supported appropriately. People told me that staff were always very helpful when they needed them. Some comments made by people were, The staff at Mulgrave House provide a very good standard of care. I can only congratulate them on their efforts. The nursing and care staff of this home are generally very caring and professional in their approach to their work. I can always find a member of staff if I need some assistance. I am very happy with the care and attention my mum gets from the staff. They are very friendly and helpful. There is a medication policy in place and the manager showed evidence that medications are regularly audited, this is good practice. Evidence was also seen to show that people who took their own medication consented to this process after assessment. Controlled drugs were stored and recorded correctly. There were some instances that showed only one signature was recorded when a controlled drug was administered. The manager was shown evidence that showed staff are not properly recording the medication administered in the home. This is not good practice. Care Homes for Older People Page 13 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are provided with a good standard of activities that help meet their social and spiritual needs. Evidence: People told us they enjoyed the activities that were on offer at the home. They said they had opportunities to visit places outside as well. A poster was displayed during the inspection informing people of a planned visit to the Royal armories. There was evidence available of visits to other local attractions. An activities coordinator is employed by the home for four hours a day four days a week. She has developed activities care plans for everyone and records showed that each person had a record made of what activity they were involved in. Recent events included: A pantomime; carol concert; Christmas Fayre; Nostalgia themed slide show and a local entertainer. There were some activities provided during the inspection that seemed to be enjoyed by people involved. It was recommended that the activities coordinator develop her role through accessing a training course at a local college. The activities coordinator and the manager agreed this would be a bonus to the home as it would assist the staff with providing an improved activities programme. One person Care Homes for Older People Page 14 of 27 Evidence: spoken to during the visit said, Dad has been on several outings and has enjoyed them a lot. People told us that they have regular contact with church representatives that come to the home. One person said that her mum is seen often and regularly took communion. The cook was able to provide evidence of how she provides meals that are to the tastes of people who live there. Records were seen of peoples likes and dislikes and this was incorporated into the menus. The menus are changed regularly in an attempt to ensure people dont become bored with the food. Positive feedback was received from people when they were asked about the quality of the food provided. The lunchtime meal was observed and those people that needed assistance with eating their meals received it from staff in a dignified and helpful manner. The kitchen has recently been assessed by environmental health and they are awaiting their star rating. The environment team did highlight that a fridge in the kitchen was erratic as it did not hold correct temperatures. Care Homes for Older People Page 15 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are appropriately protected by the safeguarding measures put in place by the home. Evidence: The home has a complaint procedure that reflects what each partys responsibilities are within the process. People told us they knew how to complain and that they were positive their complaints would be managed and dealt with correctly by the manager. The home also has a safeguarding policy but this was not displayed and was therefore not accessible to staff if needed. All but one member of staff showed a good awareness of what was meant by adult abuse and what their responsibility was if they needed to manage an abusive situation. The manager could not find the safeguarding policy as it was stuck behind another policy in the file. People contacted as part of the inspection said they felt safe in the home and they knew what to do if they were unsure of something or someone. Staff do receive regular training in safeguarding vulnerable people. There were some that had not yet received the training but this was planned for the near future. The in-house trainer is on the list to complete the train the trainer course for safeguarding vulnerable. This will make it easier to update staff in this area. Care Homes for Older People Page 16 of 27 Care Homes for Older People Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is clean and well decorated. Evidence: The owners of the home have made many improvements within the service since the last inspection. An new extension has been built to a high standard. Many bedrooms have also been redecorated to a good standard also. A new walk-in bath/shower room has been completed and is accessible to all residents. The providers have spent a substantial amount of money on improving the environment in the home and have plans to invest for more improvements in the coming year. This is commended. The provider said that with the exception of four people all others have adjustable nursing beds to assist. A kitchenette has been developed for families to use at their convenience. People told us that the standard of cleanliness in the home is good. They said, They are always cleaning the many areas of the home. Its very clean. Cleaner than my own house. All areas of the home seen during the inspection appeared clean and tidy. It was identified during the inspection that a person living in the home had a suspected infection and that she should be isolated to prevent a spread of infection. It Care Homes for Older People Page 18 of 27 Evidence: was recommended as good practice to highlight this risk to all those involved in care provision that this isolation and barrier nursing is taking place. The inspector entered the room without any prior knowledge that there was a possible infection risk present in the room. Care plans should also have been altered to reflect these changes in care need provision. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive their care from a staff group that is well trained and recruited. Evidence: The staffing levels on duty at the home during the site visit appeared to be appropriate for ensuring the care needs of people were met. Evidence gathered from staff, people who use the service and relatives suggested that the staffing levels in the home are good. Positive comments were provided about the competency of the staff group as well. People said. The staff seem to know what they are doing. The staff seem very happy and competent in their roles. There is an in-house trainer who helps develop staff through implementation of a structured training programme. All staff are provided with an induction programme that is developed around the common induction standards. This is good practice. Good evidence was available to show people are provided with a structured training programme. The majority of staff said that they are well supported by the home to develop their knowledge base through training. Some comments were, My induction was great. The service does well with training, meetings and staff updates. the standard of training has improved greatly since the new manager took over. I had a long list that had to be ticked off before I could start work by myself. Care Homes for Older People Page 20 of 27 Evidence: The manager confirmed that the staff group have not yet attained the recommended 50 to be trained to National Vocational Qualification Level 2 status. However, this target will be met in the near future. The recruitment policy is in place and the recruitment files for two of the most recent employees showed that carers are properly recruited following strict recruitment procedures. Care Homes for Older People Page 21 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assured that the care provision in the home is well structured and managed. Good systems are in place to review and improve care provision. Evidence: The new manager has settled in well and has been quick to make improvements that have been recognised by all staff spoken to. She is in the process of completing the process of registration as manager with the CSCI. There is a clear management structure that is recognised by staff, people who live there and also relatives. Good feedback was received about the positive impact the manager has had on care provision. I was provided with some negative comments from some staff that were working in the home. They had concerns about management attitudes towards them and the negative way they felt they were being managed. This information was passed over to Care Homes for Older People Page 22 of 27 Evidence: the manager and the owner during feedback at the end of the inspection for them to address using their internal management processes. People told us about staff meetings, resident meeting and regular appraisal. The manager confirmed that they are still having difficulty with ensuring staff receive regular supervision. This was evidenced through looking at records. It was recommended that an improved supervision programme be developed for staff to ensure appropriate supervision is provided. The manager has developed audit systems that help assure the quality of care given. Regular audits are carried out on care plans, complaints, medication and falls. It was highlighted that the medication audit is reviewed, as it did not pick up the administration errors seen by the inspector during the visit. Residents and staff fill in quality assurance surveys. The manager had not yet correlated this information. Peoples monies are held by the home in a safe. This money is only used for small things such as hairdressing, papers or cigarettes. The home keep a record and receipts of these money exchanges. It was identified that when the manager is off people do not have access to their money. It was recommended that a new system is developed to ensure people have access to their money when they want it. Good health and safety practices were seen during the day. A complete record of the health and safety checks were seen and these were completed monthly. Care Homes for Older People Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Staff must ensure the 31/03/2009 administration of medication of medication is correctly recorded at all times. This will ensure people receive their medication safely. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 It is recommended that when changes with care needs are identified staff should ensure the care plans are altered to recognise the change in need. Staff working at the home should not place restrictions on people unnecessarily. If a person is unsafe to smoke or there are not enough staff on to assist a person with this then it should be clearly documented and agreed with that individual. It is recommended that the activities coordinator receives training in this area. This will help develop her role and will in turn have a positive impact on the people who live in the home. The safeguarding policy should be displayed in a prominent Page 25 of 27 2 10 3 12 4 18 Care Homes for Older People place so that staff are able to access the procedure so that an incident can be easily made when needed. 5 26 Appropriate measures should be used to ensure control of infection is robust. When a person is suspected of having an infection appropriate action must be taken. This includes informing all stakeholders about risk and ensuring proper equipment is available and used by staff when entering and leaving a room where an infection may be present. It is recommended a more structured approach is taken with staff supervision. Staff are not receiving supervision as recommended in the National Minimum Standards. The manager should develop a system that ensures people have access to their own money when she is not present in the care home. 6 33 7 35 Care Homes for Older People Page 26 of 27 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!